COLUMBIA  LIBRARIES  OFFSITE 

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HX00028304 


*    SJLJ  / 

scis»cts 


PLATE   I. 


VEETICAL  MESIAL  SECTION  THKOUGH  BODY  OF  WOMAN  DYING  IN  LABOUR, 
WITH  UNRUPTURED   MEMBRANES  PROTRUDING  FROM  VULVA. 


OBSTETRICS 


A    TEXT-BOOK  FOR   THE  USE  OF  STUDENTS 
AND    PRACTITIONERS 


BY 

J.  WHITRIDGE  WILLIAMS 

PROFESSOR  OF   OBSTETRICS,    JOHNS   HOPKINS    UNIVERSITY  \    OBSTETRICIAN-IN-CHIEF 

TO    THE   JOHNS    HOPKINS    HOSPITAL;    GYNAECOLOGIST    TO    THE    UNION 

PROTESTANT    INFIRMARY,    BALTIMORE,    MD. 


WITH  EIGHT  COLOURED  PLATES  AND 
SIX  HUNDRED  AND  THIRTY  ILLUSTRATIONS  IN  THE  TEXT 


NEW  YORK  AND  LONDON 

D.    APPLETON    AND    COMPANY 

1903 


)4 


Copyright,  1903 
By  D.    APPLETON  AND  COMPANY 

Published  February,  1903 


PpaxTED  at  The  Appleton  Press 


TO 
WILLIAM    H.    WELCH, 

PROFESSOR    OF    PATHOLOGY. 
JOHNS  HOPKINS   UNIVERSITY, 

AND 

WILLIAM    T.    COUNCILMAN, 

PROFESSOR    OF    PATHOLOGY, 
HARVARD    UNIVERSITY, 


AS  A  SLIGHT  EXPRESSION   OF 
RESPECT   AND    AFFECTION. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/obstetricstextbOOwill 


P  It  E  FACE 


In  the  following  pages  I  have  attempted  to  set  forth,  as  briefly  as 
seemed  to  he  consistent  with  thoroughness,  the  scientific  basis  for  and  the 
practical  application  of  the  obstetrical  art. 

Especial  attention  has  been  devoted  to  the  normal  and  pathological 
anatomy  of  the  generative  tract,  in  the  hope  that  the  book  may  prove 
serviceable  as  a  laboratory  guide  for  students.  At  the  same  time  I  have 
endeavoured  to  present  the  more  practical  aspects  of  obstetrics  in  such  a 
manner  as  to  be  of  direct  service  to  the  obstetrician  at  the  bedside. 

]STo  pains  have  been  spared  in  illustrating  the  work,  although  mere 
artistic  effect  has  necessarily  often  been  sacrificed  to  accuracy  and  prac- 
tical teaching  qualities.  With  the  exception  of  those  relating  to  pure 
embryology,  all  illustrations  representing  microscopical  sections  have  been 
drawn  from  my  own  specimens  under  my  direct  personal  supervision,  and 
are  accurate  reproductions  of  the  originals.  The  drawings  and  diagrams 
illustrating  labour  and  its  mechanism  for  the  most  part  represent  the 
woman  on  her  back,  thus  affording  a  closer  correspondence  with  the  actual 
conditions  encountered  in  practice.  The  representations  of  the  various 
operative  procedures  have  been  redrawn  from  photographs  taken  from  life. 

Although  no  attempt  has  been  made  to  present  a  complete  bibliography, 
I  have  endeavoured  to  give  at  the  end  of  each  chapter  such  references  to 
the  early  history  as  well  as  to  the  most  recent  advances  in  each  subject,  as 
to  enable  the  student  to  refer  readily  to  the  most  important  original 
sources.  In  order  to  insure  accuracy,  the  individual  articles  have  been 
consulted  in  every  case. 

In  conclusion,  I  desire  to  express  my  appreciation  of  the  excellent  work 
of  Miss  Katherine  M.  Montague  and  Mr.  F.  S.  Lockwood  in  the  prepara- 
tion of  the  illustrations,  and  to  thank  my  various  assistants  and  my 
stenographer  for  most  valuable  aid.  I  am  under  very  many  obligations  to 
my  friend,  Dr.  Frank  E.  Smith,  for  the  revision  of  the  text  and  for  many 
suggestions  which  have  added  materially  to  its  clearness. 

Baltimore. 


CONTENTS 


SECTION   I 
ANATOMY 

CHAPTER  PAOI 

I.    The  Pelvis 1 

II.    The  Female  Organs  of  Generation 23 

The  external  generative  organs 23 

The  vagina 31 

The  non-pregnant  uterus 35 

The  Fallopian  tubes 51 

The  ovaries 55 

SECTION  II 
PHYSIOLOGY  AND  DEVELOPMENT  OF   OVUM 

III.  Menstruation  and  Ovulation 74 

Menstruation 71 

Relation  between  menstruation  and  ovulation 7<> 

Migration  of  ovum 7* 

Place  of  meeting  of  ovum  and  spermatozoa 80 

IV.  Maturation,  Fertilization,  and  Development  of  Ovum    ....  84 

Maturation  of  ovum 84 

Fertilization  of  ovum 86 

Development  of  ovum 87 

Formation  of  amnion  and  chorion '■>'■'• 

Structure  of  chorion '.is' 

Structure  of  amnion 104 

Decidua 105 

Development  of  placenta 113 

Placenta  at  full  term 110 

Umbilical  cord 12'2 

Umbilical  vesicle 134 

V.    The  Fcetus 128 

Foetus  in  the  various  months  of  pregnancy 128 

Child  at  full  term 132 

Physiology  of  fcetus 137 

vii 


Till 


OBSTETRICS 


SECTION  III 
PHYSIOLOGY  OF  PREGNANCY 

CHAPTER 

VI.    Changes  in  the  Maternal  Organism  resulting  from  Pregnancy 
Uterus   . 

Tubes  and  ovaries 
Vagina  . 

Abdominal  walls  . 
Breasts  . 
In  rest  of  the  body 

VII.    Diagnosis  of  Pregnancy,  etc. 

Signs  and  symptoms  of  pregnancy 
Differential  diagnosis  of  pregnancy 
Spurious  pregnancy 
Duration  of  pregnancy. 
Estimation  of  date  of  confinement 

VIII.    Management  of  Normal  Pregnancy 

IX.     Presentation  and  Position  of  Fcetus 
Nomenclatui-e        .... 
Reasons  for  the  predominance  of  head  presentations 
Methods  of  diagnosing  presentation  and  position  of  fcetus 


PAGE 

145 
145 
150 
150 
151 
152 
152 

157 
157 
167 
168 
170 
171 

175 

180 
182 
185 
186 


SECTION  IV 

PHYSIOLOGY  OF  LABOUR 

X.    Physiology  and  Clinical  Course  of  Labour 193 

Cause  of  the  onset  of  labour 193 

Physiology  of  labour  pains 196 

Clinical  course  of  labour 199 

XL    Forces  concerned  in  Labour 208 

Cervix  in  latter  part  of  pregnancy       .        .        .        .        .        .        .        .  208 

Lower  uterine  segment 209 

Changes  in  uterus  during  first  stage  of  labour 213 

Changes  in  uterus  during  second  stage  of  labour 216 

Forces  concerned  in  labour 218 

Changes  in  vagina  and  pelvic  floor  during  labour 220 

XII.     Mechanism  of  Labour  in  Vertex  Presentations 227 

Left  and  right  occipito-iliac  anterior  presentations 227 

Right  and  left  occipito-iliac  posterior  presentations 238 

Changes  in  shape  of  bead 243 

XIII.  Mechanism  of  Labour  in  Face,  Brow,  and  Breech  Presentations  .        .  246 

Face  presentations 246 

Brow  presentations 253 

Breech  presentations 256 

XIV.  Physiology  and  Management  of  Third  Stage  of  Labour         .        .        .  264 

Mode  of  delivery  of  placenta 265 

Clinical  picture  of  third  stage  of  labour 268 

Management  of  third  stage  of  labour 270 


CONTENTS 


IX 


CHAPTER 

XV. 


XVI. 


XVI L. 


XVIII. 


I'AUK 

Conduct  oi   Normal  Labour 

Preparations  Cor  labour .';."> 

Conduct  of  first  stage  of  labour ■.■;; 

Conducl  of  second  stage  of  labour 

Anaesthesia 29] 

Repair  of  lacerated  perinteum 205 

The  Puerperium :;<n 

Anatomical  changes  in  the  puerperium :joi 

Clinical  asj t  of  the  puerperium 804 

Care  of  patient  during  puerperium 308 

The  Newly  Born  Chili 314 

Circulatory  changes 814 

Care  of  the  umbilical  cord 315 

Care  of  eyes 316 

Stools  and  urine '.        .        .        .        .  :;17 

Anatomy  of  breasts  and  lactation 318 

Nursing 321 

Care  of  breasts 323 

Artificial  feci  liny 323 

Multiple  Pregnancy 326 


SECTION   V 

OBSTETRIC  SURGERY 

XIX.    Induction  of  Abortion  and  Premature  Labour 336 

Preparations  for  obstetrical  operations 336 

Induction  of  abortion 338 

Induction  of  premature  labour 341 

Accouchement  force 347 

XX.    Forceps 351 

History 352 

Functions 356 

Indications 356 

Application  of  low  forceps 362 

Application  of  mid  forceps 366 

Application  of  forceps  in  obliquely  posterior  presentations  .        .        .  3G8 

Application  of  high  forceps 373 

Axis  traction  forceps 374 

Use  of  forceps  in  face  presentation .377 

Use  of  forceps  in  breech  presentations 378 

XXI.    Extraction  and  Version 381 

Extraction  in  breech  presentations 381 

Cephalic  version 392 

Podalic  version 394 

Combined  version 397 

XXII.     Cesarean  Section  and  Symphyseotomy 400 

History 400 

Indications 402 

Operative  technique 403 

Prognosis 408 

Symphyseotomy 410 


OBSTETRICS 

CHAPTER  PAGE 

XXIII.  Destructive  Operations 418 

Craniotomy 418 

Embryotomy 423 

Evisceration 424 

Decapitation.        .                 424 

XXIV.  Operative  Procedures  which  do  not  Aim  at  Delivery    .        .        .  427 

Douche 427 

Curettage 429 

Tampon  or  pack 431 

Manual  removal  of  placenta         . 432 


SECTION  VI 


PATHOLOGY  OF  PREGNANCY 

XXV.    Accidental  Complications  of  Pregnancy  due  to  Disease        .        .  435 

Acute  infectious  diseases 435 

Chronic  infectious  diseases 438 

Diseases  of  circulatory  and  respiratory  systems 441 

Diseases  of  alimentary  tract  and  liver 444 

Diseases  of  kidneys  and  urinary  tract .        .        .        ...        .        .  445 

Diseases  of  the  nervous  system 447 

Diseases  of  blood 448 

Diseases  of  skin 449 

Surgical  operations  during  pregnancy 450 

XXVI.    Complications  resulting  directly  from  Pregnancy  ....  455 

Toxasmia  of  pregnancy  and  albuminuria 455 

Pernicious  vomiting  of  pregnancy 460 

Other  diseases 463 

XXVII.    Complications  due  to  Diseases  and  Abnormalities  of  the  Genera- 
tive Tract 467 

Diseases  of  vulva  and  vagina •        •        •  467 

Diseases  of  the  cervix 468 

Developmental  abnormalities  of  uterus 468 

Displacements  of  uterus 472 

Diseases  of  decidua 4/9 

XXVIII.    Diseases  and  Abnormalities  of  Ovum 485 

Diseases  of  chorion 

Deciduoma  malignum 

Diseases  of  amnion 

Abnormalities  of  placenta ^ 

Diseases  of  placenta 

Abnormalities  of  umbilical  cord 508 

Foetal  syphilis 

XXIX.    Abortion,  Miscarriage,  and  Premature  Labour        .        .        .        -521 

CJQO 

XXX.    Extra-Uterine  Pregnancy 


CONTENTS 


\' 


OHAPTEB 

XXXI. 


XXXII. 


XXXIII. 


XXXIV 


XXXV 


XXXVI. 


SECTION    VI] 
PATHOLOGY   I  >F    LABOUR 

PAGE 

Dystocia  due  to  Anomalies  01    Expulsive  Forces     ....  562 

Prolonged  labour 662 

Precipitate  labour 567 

Tetanic  conl  racl  ion  of  uterus 561 

Dystocia  due  to  contraction  of  Bandl's  ring .".<;; 

Eour-glass  contraction  of  uterus 568 

Dystocia  due  to  Abnormalities  oi   Generative  Tract     .       .       .  569 

Atresia  of  vulva 569 

Atresia  of  vagina 569 

Stenosis  and  rigidity  of  cervix ."iTl 

Dystocia  due  to  uterine  displacements 572 

Dystocia  following  ventrofixation  of  uterus 572 

Dystocia  due  to  tumours  of  generative  tract  and  pelvis     .       .        .574 

Contracted  Pelves 580 

History 580 

Frequency 581 

Methods  of  diagnosis 583 

Pelvimetry 584 

Classification 594 

Anomalies  due  to  Abnormal  Malleability  of  Pelvic  Bones  .        .  598 

Flat,  non-rhachitic  pelvis 598 

Nature  and  pathology  of  rhachitis 601 

Flat,  rhachitic  pelvis 603 

Generally  contracted,  flat  rhachitic  pelvis 606 

Generally  equally  contracted  rhachitic  pelvis 606 

Pseudo-osteomalacic  rhachitic  pelvis 607 

Nature  and  clinical  history  of  osteomalacia 610 

Osteomalacic  pelvis 013 

Anomalies    due   to   Abnormal    Malleability    of    Pelvic    Boxes — 

{Continued) 616 

Effect  of  contracted  pelves  upon  course  of  labour      ....  616 

Mechanism  of  labour  in  simple  flat  and  flat  rhachitic  pelves     .         .  618 
Mechanism  of  labour  in  generally  contracted  flat,  and  generally 

equally  contracted  rhachitic  pelves 621 

Course  of  labour  in  contracted  pelves 622 

Treatment  of  labour  complicated  by  contracted  pelves      .        .        .  628 

Abnormal  Pelves  resulting  from  Primary  Anomalies  of  Develop- 
ment          638 

Generally  enlarged  (justo-major)  pelvis 638 

Generally  contracted  (justo-minor)  pelvis 638 

Masculine  pelvis 640 

Infantile  pelvis 641 

Dwarf  pelvis 641 

Obliquely  contracted  or  Naegele  pelvis 643 

Transversely  contracted  or  Robert  pelvis 648 

Split  pelvis 649 

Assimilation  pelvis 651 


Xll 


OBSTETRICS 


CHAPTER 

XXXVII. 


XXXVIII. 


XXXIX. 


XL. 

XLI. 


XLII. 


XLIII. 


PAGE 

Pelvic  Anomalies  due  to  Disease  of  the  Vertebral  Column        .  654 

Kyphotic  pelvis 654 

Scoliotic  pelvis 660 

Kypho-scolio-rhachitic  pelvis       . 663 

Spondylolisthetic  pelvis 663 

Pelvic   Anomalies   resulting   from   Abnormal   Direction  of  the 

Force  exerted  by  Femora 671 

Coxalgic  pelvis 672 

Luxation  pelvis 673 

Atypical  deformities  of  pelvis      .        .        .        .        .        .        .        .  676 

Dystocia  due  to  Abnormalities  in  Development  or  Presentation 

of  Foetus 678 

Excessive  development 678 

Malformation  of  foetus 680 

Deformities  of  foetus 681 

Hydrocephalus      .        .        . .  682 

Enlargement  of  the  abdomen  of  foetus 683 

Transverse  presentations 686 

Eclampsia 693 

hemorrhage 713 

Premature  separation  of  the  normally  implanted  placenta        .        .  713 

Placenta  praevia .        .717 

Post-partum  haemorrhage 725 

Inversion  of  uterus .        .  730 

Injuries  to  Birth  Canal 734 

Injuries  to  vulval  outlet 734 

Injuries  to  vagina         . 734 

Injuries  to  cervix 736 

Rupture  of  uterus 738 

Instrumental  perforation  of  uterus 744 

Perforation  of  genital  tract  following  necrosis 745 

Prolapse  of  Umbilical  Cord,  etc 747 

Asphyxia 749 

Sudden  death  during  or  shortly  after  labour 753 


SECTION  VIII 
PATHOLOGY  OF   THE  PUERPERIUM 

XLIV.    Puerperal  Infection 757 

XLV.    Diseases  and  Abnormalities  of  the  Puerperium       ....  797 

Tetanus 797 

Thrombosis  of  vessels  of  lower  extremities 798 

Gangrene  of  lower  extremities 799 

Diseases  of  urinary  tract .        .        .  799 

Haemorrhages  during  puerperium 800 

Diseases  and  abnormalities  of  uterus 802 

Obstetrical  paralysis 805 

Abnormalities  and  diseases  of  breasts         .        .        .        .        .        .  807 

Puerperal  psychoses 812 

Acute  infectious  diseases  during  puerperium 814 

Index 819 


LIST   OF    PLATES 

PAcnra 

PLATE  ,.A,,f; 

I.    Frozen  section  through  woman  dying  at  beginning  of  second  stage  of  labour, 

breech  presentation Fronti 

II.     Showing  several  varieties  of  hymen - 

III.  Section  through  endometrium  on  third  day  of  menstruation   .        .        .        .75 

IV.  Peters's  ovum 95 

V.     Section  through  four-months'  placenta,  showing  junction  of   chorion   and 

decidua 11. "j 

VI.     Terminal  chorionic  villus  with  injected  vessels 116 

VJLL     Corrosion  preparation  of  mature  placenta,  to  show  fa-tal  vessels     .        .         .lift 

VIII.     Foetal  circulation i:js 

IX.     Seven  and  a  half  months'  pregnant  uterus  from  woman  dying  in  first  - 

of  labour 212 

X.     Palpation  in  left  occipito-iliac  anterior  presentation 228 

XL     Palpation  in  right  occipito-iliac  posterior  presentation •.':;'.• 

XII.     Palpation  in  right  mento-iliac  presentation 247 

XIII.  Palpation  in  left  sacro-iliac  presentation 257 

XIV.  Placental  infarct  formation .",114 

XV.     Palpation  in  left  acromio-iliac  dorso  anterior  presentation      ....  687 

XVI.     Section  through  endometrium  in  streptococcic  puerperal  infection         .        .     706 


LIST   OF  TEXT   ILLUSTRATIONS 


Section  I. — Anatomy 
Clitoris  and  its  vascular  supply 
Fallopian  Tube. 

accessory  ostium  of 
ampullar       portion       of,       section 
through      ..... 
isthmie  portion  of,  section  through 
longitudinal  folds  of  mucosa  of 
mucosa  of,  highly  magnified 
uterine  portion  of,  section  through 
Hymen. 

almost  unruptured,  after  childbirth 
section   through   lower   portion    of 
vagina  of  14-eentimetre  embryo, 
showing  development  of 


PAGE 

26 

54 

52 
52 
53 
51 
52 

30 


29 


Ovary.  , 

adult,  cross-section  through,  show- 
ing follicles        .... 

corpus  fibrosum     .... 

corpus  fibrosum,  later  stage  . 

corpus  luteum  of  pregnancy,  with 
cystic  centre       .... 

corpus  luteum.  section  through, 
showing  lutein  cell~   . 

development  of,  section  showing 
Wolffian  body  and  Miillerian 
duct  ..... 

mature  follicle,  section  through 
wall  of      ....  . 

of  S-months'  foetus,  section  through 


57 
69 
69 

67 

GS 


58 

65 
59 


XIV 


OBSTETRICS 


Ovary.  page 
of  new-born  child           .          .          .00 
of    new-born    child,    showing    pri- 
mordial  follicles,   highly   magni- 
fied               01 

of  pig  embryo,  section  through      .     59 
of  young  woman,  showing  develop- 
ing  follicle         .  .  .  .62 
of    young    woman,    showing    more 

advanced  follicle         .  .  .02 

of  young  woman,   showing  nearly 

mature  Graafian  follicle      .  .     03 

of    young    woman,     showing    pri- 
mordial follicles  .       '  .  .     G2 
Pelvis. 

antero-posterior  diameter  of,  varia- 
tions in  ...  .11 
Breisky's  diagrams  for  comparing  .     12 
disarticulated,      of      three-year-old 

girl 17 

female,  front  view  .  .  .13 

male,  front  view   .  .  .  .13 

normal  female       ....       2 
normal  female,   showing  diameters 

of  superior  strait       ...       5 
normal     female,     sagittal     section 

through       .....       4 
outlet   of  .  .  .  .7 

plane  of  greatest  dimensions  of     .       7 
plane  of  least  dimensions  of  .  .8 

planes  of,  diagram  showing  .  .       6 

sacro-iliac  synchondrosis         .  .11 

sacrum,  diagram  showing  that  it  is 

not  the  keystone  of  the  arch       .       4 
sagittal    section    showing    relative 
proportion  of  bone  and  cartilage 
in  pelvis  of  new-born  child  .      10 

sagittal    section    through   body   of 

adult  woman      .  .  .  .18 

sagittal    section    through    body    of 

neAv-born  child  .  .  .18 

section  parallel  to  superior  strait, 
showing  relative  proportion  of 
bone  and  cartilage  in  new-born 

child 16 

section  through  adult,  diagram  of    20 
section  through  infantile,  diagram 

of 20 

section  through  pelvis  of  five-year- 
old  girl 17 

sexual      differences      of,      diagram 

showing      .  .  .  .  .14 

superior  strait  of  .  .  .  .7 


Pelvis. 

symphysis  pubis,  frontal  section 
through      .  .  ... 

Veit's  main  plane  of 
Uterus,  Xon-pregnant. 

anterior    aspect   of 

blood  supply  of 

broad  ligament,  section  through 
uterine  end  of   . 

cervical  canal,  cross-section  through 

cervical  gland 

cervix  and  vagina,  junction  of 

endometrium,  highly  magnified, 
showing  uterine  gland  and 
stroma        .... 

endometrium,   normal    . 

endometrium   of   new-born  child 

endometrium,   senile 

external   os,   parous       .  .  . 

external  os,  virginal 

lateral  aspect  of,  showing  supra- 
vaginal and  infravaginal  por- 
tions of  cervix,  and  arrangement 
of  peritoneal  covering 

lymphatic  supply  of 

nerve  supply  of 

of  young  child,  with  appendages  . 

of  fourteen-year-old  girl,  with  ap- 
pendages    ..... 

of  twenty-one-year-old  woman, 
with  appendages 

posterior  aspect  of 

reconstruction  of,  showing  shape  of 
uterine  cavity  and  cervical  canal 
Vagina. 

H  -shaped  lumen  of 

longitudinal  section  showing  de- 
velopment of  .  .  . 

mucous  membrane  of   . 
Vulva. 

of  multiparous  woman,  labia 
spread  apart      .... 

of  primiparous  woman,  labia  in 
contact       ..... 


10 


35 

40 

44 
38 
39 
36 


42 
40 
41 
41 
38 
38 


36 

47 
48 
37 

37 

37 
35 

40 

32 

29 
33 


24 


24 


Section  II. — Physiology  and  De- 
velopment of  Ovxm 

Decidua. 

non-pregnant  endometrium,  highly 
magnified,  showing  structure  of 
gland  and  stroma      .  .  .109 

reflexa,  Coste's  theory  of  formation. 
of 100 


LIST   OP  TEXT   ILLUSTRATIONS 


xv 


Decidua.  , 

refiexa,  Hunterian  theory  of  for- 
mation of  . 

refiexa  in  situ,  in  seA  enteen  daj  a' 
pregnanl   uterus 

refiexa  in  situ,  in  aix-weeks'  preg 
iiaiit    uterus        .... 

serotina,  section  showing  mixture 
of  foetal  and  maternal  cells 

vera,  fourth  month 

vera,    fourth    month,    highly    mag- 
nified ..... 
Embryo. 

early   human  .... 

human,  from  fourth  and  fifth 
weeks         ..... 

human,  from  second  month   . 

head  of  new-born  child,  showing 
accessory,  small  and  large  fonta- 
nelles  ..... 

skull  of  new-born  child,  showing 
fontanelles,  sutures,  and  diam- 
eters ..... 

skull    of    new -born    child,    showing 
sutures  and  diameters 
Ovum. 

blastodermic  vesicle,  mammalian  . 

blastodermic  vesicle  of  rabbit 

chicken  embryo  with  five  seg- 
ments ..... 

chicken  embryo  with  seven  seg- 
ments,   section    through 

chorionic  villus  at  ninth  month    . 

chorionic  villus  at  third  month 

chorionic   villus  at  third  week 

embryonic  area  of  rabbit 

embryonic  shield  of  rabbit,  show- 
ing primitive  streak  and  medul- 
lary fold     ..... 

embryonic  shield  of  sheep,  section 
through      ..... 

female   pronucleus,  formation  of    . 

female  pronucleus,  fusion  with 
male  pronucleus 

human   (Leopold's),  seven-days' 

human,  seven  days",  embedded  in 
decidua  and  surrounded  by  de- 
cidua refiexa      .... 

human    'Leopold's),  two-weeks'     . 

human  (Peters's),  highly  magni- 
fied, showing  early  stage  in  de- 
velopment of  embryo 

human    (Reiehert's) 


•age      Ovum. 

human,  x\  <n  to  eight   daj  -',  em- 
105  bedded  in  ut<  rua         .         .         .104 

human   (Spee),  embryonic  area  ".  1 

110  millimetre  long  ....     DO 
human       (Spee),      1      millimetres 

111  long !»l 

human,      Sim-c'-      older.      section 

112  through  embryonic  area  of  03 

107  human,      Spee's      older,      section 

through 09 

108  human,    Spec'-    youngest,    section 

through  embryonic  area   "t"        .     02 
128  human.    Spee'-    youngest,    section 

khrough 98 

I-'1  human,  two  week-',  section  through 

130  chorion  of  ....    101 

Hylobates's,  Bection  through,  show- 
ing formation  of  amnion      .  .   100 
13G          mammalian    embryo,    longitudinal 
in  through,  showing  forma- 
tion  of   amnion            .          .  .02 
135          mammalian  embryo,  transverse  sec- 
tion through,  -bowing  formation 
134               of  amnion            .          .          .  .04 

mesoderm,  diagram  showing  exten- 
87  sion  of 89 

87  mulberry  mass,  formation  of  .     86 
polar  body,  formation  of  .84 

91  rabbit,    section    through,    showing 

three   layers       .  .  .  .89 

92  segmentation  nucleus,  changes  in  .  v'i 
102  segmentation  of  .  .  .  .  SG 
1°2           spermatozoa           .... 

102  syncytium,     conversion     of     tubal 

88  epithelium   into  .  .  .    103 
Placenta. 

fcetal     membranes     in     connection 
90  with  uterine  wall        .  .  .121 

fcetal  surface  of   .  .  .  .   120 

89  maternal      surface      of,      showing 

85  cotyledons  .  .  .  .120 

section  through  eight  months'       .    117 

85       Umbilical  Cord. 

9G  abdominal  pedicle,  section  showing 

development  of  .  .  .  .123 

epithelium  of  ...  .    122 

97  foetal  end  of.  showing  vessels  and 

96  umbilical  stalk  .  .  .122 

of  young  embryo,  diagram   of       .    124 
section  of,  highly  magnified,  show- 

0s  ing  stalk  of  umbilical  vesicle       .   123 

88       Umbilical   vesicle       .  .  .  .124 


XVI 


OBSTETRICS 


Section  III.— Physiology  of 

Pregnancy  page 

Abdomen  of  primipara  at  term,  show- 
ing striae    .  .  .  .  .151 
pendulous,  of  multiparous  woman 
with  normal  pelvis     .          .  .162 
Abdominal     enlargement     at     ninth 

month  of  pregnancy  .  .  .    161 

at  sixth  month  of  pregnancy  .    161 

at  tenth  month  of  pregnancy         .    161 
at  third  month  of  pregnancy  .    161 

Breech  presentations,  diagram  show- 
ing varieties  of  .  .  .  .183 
Face   presentations,    diagrams   show- 
ing varieties  of  .          .          .          .   1S3 
Foetus  in  brow  presentation       .          .181 
in  breech  presentation   .          .          .181 
in  face  presentation       .          .          .    181 
in  foot  presentation       .          .          .181 
.   in  frank  breech  presentation  .          .181 
in  knee  presentation      .          .          .181 
in  sinciput  presentation           .          .    181 
in  vertex  presentation   .          .          .    1S1 
Fundus,  relative  height   of,   at  vari- 
ous weeks  of  pregnancy      .          .172 
Hegar's  sign,  method  of  detecting       .    163 
Muscle  fibres  from  non-pregnant  and 

pregnant  uterus  .  .  .145 

Pregnant     uterus,     external     muscle 

layer  of  .  .  .    146 

internal   muscle   layer  of       .  .147 

median  muscle  layer  of         .  .    147 

ten  weeks',  section  through   .  .164 

ten  weeks',  section  through,  show- 
ing     mode      of      production      of 
Hegar's  sign       ....   164 
Primipara  at  full  term  in  horizontal 

position      .....   149 
in   vertical   position       .  .  .   149 

Spurious    pregnancy,    abdominal    en- 
largement due  to  fat  .  .  .168 
Vaginal  examination,  diagram  show- 
ing method  of  differentiating  be- 
tween the  fontanelles           .          .    190 
diagram  showing  method  of  locat- 
ing sagittal  suture  in          .  .   1S9 
Vertex  presentations,  diagrams  show- 
ing varieties  of  .          .          .  .183 
Wooden  nipple  shield        .          .  .177 


Section  TV. — Physiology  of 
Labour 
Abdomen,  change  in  shape  of,  before 

and  during  uterine  contractions  198 
immediately  after  birth  of  child    .   269 
showing  rising  up  of  fundus  follow- 
ing   extrusion    of    placenta    into 
lower   uterine   segment 
Anterior  shoulder,  traction  to  bring 

about   descent   of 
Birth  of  head,  external  rotation 
face     falling     backward     towards 

anus  .... 

scalp  appearing  at  vulva 
showing  delivery  by  extension 
vulva  completely  distended   . 
vulva  partially  distended 
Birth   canal,   diagram   of,   at   end'  of 
pregnancy  .... 

diagram  of,  during  second  stage  of 
labour         ..... 
Breast,  lactating       .... 
Breech  presentation,  birth  of  head  in 

260,  261 
Brow  presentations,    diagrams   show- 
ing position  of  child  in 
Caput     succedaneum,     disappearance 

of 

Cervix  at -end  of  pregnancy  (Braune 
and  Zweifel)        .... 
(Leopold)       ..... 
(Midler's  diagram) 
(Waldeyer)  .... 

Cervix,  dilatation  of,  canal  completely 
obliterated,  external  os  intact    . 
funnel-shaped  obliteration  of  inter- 
nal os  and  cervical  canal   . 
funnel-shaped  obliteration  of  inter- 
nal os.  farther  advanced 
Saxinger's  frozen  section  showing  . 
Schroeder's  frozen  section  shoAving  . 
Tibone's  frozen  section  showing 
Winter's  frozen  section  showing    . 
Colostrum,  human    .... 
Delivery,   patient   in  proper  position 
for,  covered  by  sterile  dressings  . 
Direct    pressure    exerted    by    fundus, 
diagram  showing  action  of,  after 
rupture   of  membranes 
Engagement  does  not  occur  in  trans- 
verse diameter  of  superior  strait, 
diagram  showing  why 


269 

289 
205 

204 
200 
203 
202 
201 

214 

214 
318- 


254 
243 

209' 

209 
208 
209 

215 

214 

215 
216 
215 
217 
216 
319 

285. 


219 


231 


LIST  OF  TEXT   ILLUSTRATIONS 


w  u 


Engagement  position  of  foetus  after  . 

position  of  foetus  before 
Face  presentation,  diagram  showing 
acl  ion  of  head  lever  . 

diagram  showing  configuration  of 

head    in 

diagram  of,  showing  conversion  into 
a  vertex  by  Thoi  q's  manceu\  re  . 
diagrams  showing  delivery  of  head 
in  .  .  .'         .249, 

diagram    showing    impossibilitj    oi 
delivery    when    chin    is   directly 
posterior     ..... 
diagram  showing  thai  the  greatesl 
diameter    of    the    head    is    still 
above  the   superior  si  rait    when 
face  is  on  level  of  ischial  spines  . 
distention  of  vulva  in   . 
distortion  of  face  after  delivery    . 
due  to  tumour  of  neck  . 
Flexion,   diagram    showing  effect  of, 
conversion  of  occipitofrontal  into 
suboccipito-bregmatic  diameter  . 
Foetus  papyraceus     .... 
Frozen  section  just  after  the  comple- 
tion   of    third    stage    of   labour, 
showing  collapse  of  lower  uterine 
segment  and  cervix    . 
latter  part  of  pregnancy,  child  in 

L.  S.  I.  T 

second    stage    of    labour,    child    in 

E.O.I. A.,  membranes  unruptured 

showing    condition   of   birth    canal 

in  first  part  of  second   stage  of 

labour         . 

showing    condition   of   birth    canal 

in  first   part  of  second  stage  of 

labour        .         .         .         •         • 

showing  condition  of  birth  canal  in 

last  month  of  pregnancy  (Braune 

and  Zweifel)       .... 

showing  uterus  immediately   after 

delivery      . 
third  stage  of  labour,  showing  twin 

placentae  in  utero 
through    woman    at    end   of   preg- 
nancy, child  in  R.  0.  I.  T.  . 
through    woman   dying   in   second 
stage    of    labour,    showing    con- 
traction ring      . 
through    woman    in    labour,    with 
child  partly  delivered 


PAOI 

230 
230 


248 
25 1 
252 
250 

2  is 


252 

249 
251 

247 


233 
331 


303 
257 
233 

212 

224 

223 
301 
266 
228 

210 
236 


Head,  diagram  of,  showing  suboc 
cipito  frontal  ami  oi  her  diam- 
eter^   235 

dolicho  cepha lie,   i> om   hi eech   pri 

entation 248 

lever,  diagram   illustrating    .         .   233 
internal  rotation,  diagram  showing  .  2:;i 
diagra  ra   show  ing    direel  ion   of,   in 

K.  s.   I.   P.  position    .         .         .  259 
in  occipito-posterior  positions,  dia- 
gra in-  show  ing  .         .         .         •   -'  I" 
Intra-uterine  pressure,  diagram  show- 
ing  action   of,   after   rupture   of 
membranes         ....  218 
diagram  showing  action  of,   mem- 
branes lint    nipt  ured    .  .  .    217 
Kelh  's  rubber  pad   ....   283 
Lower   uterine   segment,  diagram   il- 
lustrating    main     views     as     to 
nature  of   .           .           .           .  •    211 
section  through,  showing  rhomboi- 
dal       arrangement      of      muscle 
fibres  in               .          .          .  •   213 
Mento-iliac     presentations,    diagrams 

showing      .....   246 

Milk,  human 319 

Needle  for  repairing  perineal  tear       .   297 

Needle  holder 297 

Obstetrical  bag  .  .  .  .271 

Occipito-iliac   anterior   presentations, 

diagrams  showing       .  .  ,    227 

Occipito-iliac  posterior  presentations, 

diagrams  showing       .          .  239 
Ovum    with    double    germinal    vesi- 
cle       327 

Palpating  head  through  perinaeum     .  284 
Pelvic   and   perineal   fascia,   arrange- 
ment of 222 

Pelvic  floor,  distended  by  presenting 

part,  showing  superficial  muscles 

of  perinaeum       ....   223 

seen  from   above   ....   220 

seen  from  below    .  .  .  .221 

Perineal  tear,  complete      .  .  .   296 

deep      ...•■•   295 

extending  up  the  vagina,  repair  of  298 

superficial       .  29o 

sutures  tied 29S 

Perinaeum,  method  of  protecting       .  2S8 
Placenta   and    membranes,   diagrams 
showing  relation   of,  in  double- 
and  -ingle-ovum  twin  pregnancy  329 


OBSTETRICS 


Placenta,   diagram   showing  relation 
of,  to  uterine  wall  in  latter  part 
of  pregnancy      .... 

diagram    showing    relation    of,    to 
uterine   wall  in  second  stage  of 
labour         ..... 

double-ovum     twins,     velamentous 

insertion  of  cord 
expression  of  ... 

extrusion  of,  by  Duncan's  mechan- 
ism    ...... 

extrusion  of,  by  Sehultze's  mechan- 
ism    ...... 

extrusion  of,  by  Sehultze's  mechan- 
ism, later  stage   .... 

Posterior  shoulder,  delivery  of  . 
Saero-iliac     presentations,     diagrams 

showing  position  of  child  in 
Synelitism,  diagram  illustrating 
Twins,  collision  between  heads  of 
diagrams   showing   position   of,   in 
utero  ..... 

locked    ...... 

Vaginal      examination,     method     of 
covering  patient  with  sheet  before 
making      ..... 

spreading    apart    the   labia    before 
making       ..... 

Vertex  presentation,  diagram  showing 
configuration  of  head  in 
diagram  showing  delivery  of  head 

in 236 

diagram  showing  delivery  of  head, 
occiput  in  hollow  of  sacrum,  241,  242 
Version. 

.  397 
.  393 


2G5 


265 

328. 
271 

268 

2G7 

267 
290 

256 
232 

333 

330 
334 


2S0 


281 


244 


bipolar  podalic 

external    cephalic 

internal  podalic,  seizure  of  foot 
in 394 

internal  podalic,  transverse  presen- 
tation, back  anterior,  seizure  of 
lower  foot  ....   395 

internal  podalic,  transverse  presen- 
tation, back  anterior,  seizure  of 
upper  foot  ....   395 

internal  podalic,  transverse  presen- 
tation, back  posterior,  seizure  of 
lower  foot,  showing  arrest  of  but- 
tocks at  pelvic  brim    .  .  .    397 

internal  podalic,  transverse  presen- 
tation, back  posterior,  seizure  of 
upper  foot  .....   396 


Section  V. — Obstetric  Surgery 

PAGE 

Balloon,  Champetier  de  Ribes's  .  .    346 

ready  for  introduction  .  .  .    346 

Basilyst,  Simpson's,  articulated  .   424 

disarticulated         ....   423 

Basiotribe 422 

Taraier's,  disarticulated  .  .   422 

Tarnier's,  effect  upon  head     .  .   423 

Blunt  hook,  Braun    ....   424 
diagrams  showing  mode  of  action 

of 425 

Cephalotribe,  Tarnier's       .  .  .   422 

Cranioelast,  Braun's  .  .  .   421 

head  crushed  by   .  .  .  .421 

Curette 429 

Decapitation     with     Braun's     blunt 

hook  .....    425 

Dilator,  Goodell's      .  .  .     -     .    340 

Reynolds's  cervical         .  .  .   349 

Douche  tube 428 

Extraction  of  Breech. 

introduction  of  finger  to  free  pos- 
terior arm  ....  385 
posterior  rotation  of  shoulder  in  .  384 
traction  upon  feet  .  .  .  3S2 
traction  upon  thigh  .  .  .  383 
Extraction  of  Frank  Breech. 

finger  in  anterior  groin  .  .   38S 

fingers  in  both  groins    .  .  .   389 

Pinard's    manoeuvre    for    bringing 
down  a  foot       ....   390 
Forceps. 

applied  along  mento-oecipital  diam- 
eter, pelvic  curve  towards  face  .   360 
applied  along  occipito-mental  diam- 
eter, pelvic  curve  towai'ds  occiput  360 
applied    obliquely    over    brow    and 

mastoid  region    ....    361 
applied    over    brow     and     occiput, 
figure  showing  extension  of  head 
and   explaining   tendency   of   in- 
strument to  fall  off     .  .  .   361 
applied     over     occiput     and     face, 
figure   showing  that  blades  can- 
not be  locked      ....    361 
applied     to     face     along     occipito- 
mental diameter          .          .  .   360 
axis  traction   (Hermann's)      .  .   376 
axis  traction   (Hubert's)         .  .   376 
axis  traction   (Morales's          .  .   376 
axis    traction,    Tarnier's.    diagram 
showing-  method  of  traction         .   380 


LIST   OF   TEXT   ILLUSTRATIONS 


XIX 


Forceps. 


Taniier'a     latesl 


axis      traction, 

model         ..... 
axis      traction,      Tarnier'a      latesl 

model,    traction    rods    in    place 

without   handle-bar     . 

traction,  Tarnier'a  original    . 
(  hambei  len's  .... 

high,    diagram    showing    defeel    of 

cephalic  application  in 
high,  Pajot's  manoeuvre  in   . 
high,  .Tarnier's    diagram    showing 

defects  of  ordinary   instruments 

in       .....  . 

lock  of  English      .... 

lock  of  French       .... 

long  French  .... 

low,  extreme  upward  traction 

low,  horizontal  traction 

low,     instrument     in     place     and 

articulated  .... 

low,  introduction   of   left   blade  to 

left  side  of  pelvis 
low.  left  blade  in  place 
low,  left   blade  in  place,  introduc- 
tion ot  right  blade 
low,   occiput  in   hollow  of  sacrum. 

horizontal  traction 
low,  occiput  in  hollow  of  sacrum, 

upward  traction 
low,   upward   traction 
mid.  diagram   showing  rotation  of 

occiput  to  sacrum 
mid.  diagram  showing  rotation  of 

occiput  to  symphysis  pubis 
mid,  hand  in  vagina  seeking  poste- 
rior ear      ..... 
mid,  instrument  applied  in  L.O.I.A. 
mid.   instrument   applied  in  R.   O. 

I.  T 

mid.   instrument   applied   in  R.   0. 

I.  T.,  rotation  to  R.  0.  I.  A. 
mid.  introduction  of  first  blade 
mid,  introduction  of  second  blade  . 
mid,  manner  of  making  traction  in 
Palfyn's         ..... 
position  of  head  in  floating,  high, 

mid,  or  low  operations 
Scanzoni's  manoeuvre,  first  applica- 
tion of  instrument  . 

second   application 

showing  difficulty  in  articulating 
blades  in  second  application    . 


■  PS. 
1  PAOI 

>liou  mg  inversion  of  ins!  i  umenl 
when  anteri tation  i-  at- 
tempted in  an  l:.  ( ).  I.  I',  posi- 
tion without  a  second  applica- 
tion ....  370 
376             Bhowing     rotation     to     anterior 

position,  in-t  1 1 1 1 in  ii i  inverted       ■' - 
Bhowing    rotation    to    transverse 
:;7 1  posil  ion  .         .         .  :;71 

376  Simpson's,  showing  cephalic  curve      351 

showing    pelvic   curve    . 
Smellie's  long         ....   •';">•"' 
37-">  shorl  .....  355 

352       Leg-holder,  Robb's    ....   358 
352       Manual  dilatation  of  cervix,  Harris's 
:;.-).-)  method       .... 

364       Mauriceau's    manoeuvre,    downward 

364  traction 386 

upward  traction    . 

363       Ovum  force],- :;il 

Pack,  vaginal  and  cervical        .  .   347 

362      Packing  the  uterus   for  post-partum 

302  haemorrhage  .  .  .  .431 
Perforation  of  head  ....    420 

303  Placenta,  manual  removal  of   .  .    433 
Prague  manoeuvre,  back  posterior     .  387 

365  Preparation  for  operation,  patient  at 

edge  of  bed  with  legs  held  in  posi- 

365  tion  by  leg-holder       .  .  .   336 

304  patient   covered  with  sterile  dre-<- 

ings 337 

369       Smellie's  scissors        ....  419 

Symphyseotomy,     diagram     showing 

369  effect  of 411 

366  Section  VI.— Pathology  of 

367  Pregnancy 

Abortion,  early,  showing  decidua  re- 
3 Os  flexa  and  serotina,  with  degener- 

ated embryo        ....   524 

305  Albuminometer,  Esbaeh's  .         .         .    157 
300       Amniotic    adhesions,    amputation    of 

307  arm  by 499 

369  amputation   of   finger-   by     . 

3.34  encephalocele  resulting  from  .         .   498 

Ampullar  pregnancy,  ruptured  .         .   539 

359       P.lood  mole 526 

Broaddigament  pregnancy         .         .  543 

371  Chorionic  villus,  normal,  teased  in  salt 

372  solution      .....   514 
syphilitic,  teased  in  salt  solution  .  514 

373  Decidua  polyposa      ....   4S0 


XX 


OBSTETRICS 


Deeiduoma     malignum,     microscopic 
section  of  . 
showing  syncytial  masses  invading 
a  venous  channel 
Diverticulum  from  lumen  of  tube 
Endometritis  decidua 

cystica  ..... 

Extra-uterine    pregnancy,    formation 
of  decidual  cells  in  non-pregnant 
tube  ..... 

microscopic  section  showing  attach- 
ment of  chorion  to  tube  Avail 
uterine   decidua   from    . 
Foetal  epiphysis,  normal   . 
microscopic  section  through  . 
syphilitic        ..... 

microscopic   section   through 
Hernia  of  pregnant  uterus 
Hernia,  inguinal,  of  pregnant  horn  of 

bieornuate  uterus 
Hydatidiform  mole    .... 

microscopic  section  through  . 
Interstitial  pregnancy 
Isthmie  pregnancy     .... 

GEdema  of  vulva       . 
Oligo-hydramnios,      compression      of 

foetus  in 
Ovarian  pregnancy  .... 

Placenta,  battledore 

bipartita        ..... 

duplex,     with     two     succenturiate 
lobules        ...... 

cyst  of  ..... 

fenestrata      ..... 

marginata     ....'. 

membranacea         .... 

normal,  full-term,  microscopic  sec 
tion  through       .... 

septuplex,  corrosion,  preparation  of  501 
syphilitic,     full-term,     microscopic 
section  through  .  .  .515 

tripartita 500 

Pregnancy  in  accessory  tubal  ostium  534 
in  rudimentary  left  uterine  horn   .   470 
Prolapsed  pregnant  uterus         .  .   477 

Retroflexed    pregnant    uterus,    incar- 
ceration of  ... 
sacculation  of        ...  . 
Toxaemia  of  pregnancy,  urea  chart: 
dietetic  treatment  without  effect ; 
accouchement  force;  recovery 
recoverv  under  milk  diet 


490 

491 
534 
4S3 
481 


547 

548 
546 
512 
513 
512 
513 
479 

478 
485 
486 
53S 
538 
464 

497 
537 
508 
500 

502 
505 
499 
502 
501 

515 


474 
473 


459 

458 


Tubal  abortion,  ovum  in  act  of  extru- 
sion through  fimbriated  extremity  541 
mole      ......   542 

pregnancy,  early,  with  abortion  of 

ovum  into  lumen  of  tube    .  .   540 

pregnancy,   showing  ovum   embed- 
ded  in   wall   of   tube   outside   of 
lumen         .....   549 

Tuberous  subchorial  hasmatoma         .   525 

Ureometer,   Doremus's       .  .  .   457 

Uterus  bicornis  duplex       .  .  .   469 

bicornis  septus       ....   469 

bicornis  subseptus  .  .  .   469 

bicornis  unicollis   ....   469 

bicornis  unicollis,  with  rudimentary 

horn  .  .  .'        .  .469 

pseudo-didelphys    ....   469 

unicornis        .....   469 

Section  VII.— Pathology  of 
Labour 

After-coming      head,      passage      of, 

through  contracted  superior  strait  621 
Aneneephalus    .  .  .  .  .681 

Anterior  parietal  presentation  .  .   619 

passage  of,  through  superior  strait  619 
Chondrodystrophia  fcetalis         .  .    640 

Chondrodystrophic  dwarf  .  .641 

Compound  presentation     .  .  .691 

frozen  section  through  woman 
dying  at  end  of  pregnancy  .   691 

Diagonal  conjugate,  diagram  showing 
effect  of  position  of  promontory  of 
sacrum  upon  length  of       .  .   590 

diagram  showing  variations  in 
length  of,  according  to  the  height 
and  inclination  of  symphysis 
pubis  .  .  .  .  .   5S9 

Eclampsia,  urea  chart;  death   .  .   69S 

urea  chart:  recovery      .  .  .697 

Eclamptic  liver,  section  showing  area 

of  necrosis  ....    700 

Elephantiasis  congenita  cystica  .   6S4 

Epiphysis,  normal,  section  through     .   600 
rhachitic,  section  through      .  .    601 

rhachitic,     section     through,     ad- 
vanced stage       ....   602 
Foetus,    with    congenital   cystic   kid- 
neys .  .       •   .  .  .   685 
with  immensely  distended  bladder  685 
Head,    pressure    marks    upon,    from 

promontory         ....    626 


LIST  OF  TEXT    ILLUSTRATIONS 


xxi 


PAGE 

Hydrocephalus,  dystocia  due  to  .  682 

Inversion  of  uterus,  complete  .   730 

Kyphosis,  Lumbo-sacral,  patienl   with  659 
Lacerated    cen  i\,    drav  n    dow  a    to 

\  ul\ .i  preparatory  to  repair        .   737 
I .iii  acromio-iliac  dorso  posterior  posi- 
tion, diagram  show  ing        .         .   686 
Luxation  of  femora,  bilateral,  side  and 

rear  views  of  patienl  w  ith  .         .   675 
Measuring      conjugata      vera      with 
Skutsch's  pelvimeter  .         .         .   591 
anterior-posterior  diameter  of  pel- 
vic outlet,  Breisky's  method        .  592 
diagonal  conjugate        .         .         .  588 
distance  between  anterior  superior 

spines  .....    ">s"> 

distance  between  tubera  isehii  .  593 
external  conjugate  .  .  .  586 
lengl  li  of  diagonal  conjugate  upon 

the  lingers  ....   589 

transverse     diameter     of     superior 
strait  with  Skutsch's  pelvimeter  .   592 
Michealis's  rhomboid  .         .         .  589 

Neglected  transverse  position,  frozen 
section  through  woman  dying  in 
labour  with         ....   088 
Ovarian  cyst,  causing  dystocia  .  .   570 

Pelvimeter,  Budin's  ....   584 

Hirst's 591 

Martin's 584 

method  of  holding  .  .  .    5S4 

Stein's 590 

Pelvis. 

assimilation,  asymmetrical     .          .   051 
assimilation,   high           .          .          .   049 
assimilation,  low   ....    050 
assimilation,       transversely       con- 
tracted         050 

chondrodystrophic  .         .         .   042 

contracted,  due  to  absence  of  bodies 

of  sacral  vertebrae        .         .         .   048 
coxalgie,  diagram  of,  after  patient 

has  walked  .  .  .  .071 

coxalgie,  diagram  of,  before  patient 

has  walked  ....  071 
coxalgie,  with  ankylosed  femur  .  072 
deformed  by  cystic  enchondroma  .  676 
flat  non-rhachitic  .  .  ■  599 
flat  rhachitic  ....  003 
flat  rhachitic,  with  double  promon- 
tory   onr, 

fractured 077 


Pelvis.  paob 

generallj  contracted      .         .         .  <;:;*> 

rail}   ■  "in  racted,  Hal   i  hachit  i<    Dor, 
genet  allj      conl  rai  ted,      rhachit  ic, 

moulding  ol  bead  in  .  .  .  024 
generallj         equally        contracted 

rhachitic  .....  miT 
kypho  scoliol  ic  i  liachil  ic  .  .  003 
k\  phol  ic,  diagram   Bhow  ing    foi  cea 

concerned  in  t  he  | Lud  ion  ol     .   657 

kyphotic,       longitudinal       section 

through  .....  65  1 
kyphotic,    showing    elongation    of 

conjugata  vera  .         .         .  655 

Naegele.  anterior  view  .         .         .till 
Naegele,  posterior  view  .         .         .  <>  15 
obliquely    contracted,   d\ic    to    uni- 
lateral luxat  ion  of  femur    .         .   ti7:J 
obliquely  conl  met  ed,  non  rhachil  ic 

scoliotic  .....  651 
obtecta  .....  656 

osteomalacic  ....   <>  1  — 

osteomalacic,      diagram      showing 

changes  in  shape  of     .  .  .   608 

osteomalacic,  interior  strail  of  .  613 
pseudo-osteomalacic  .  .  .  607 
rhachitic.  diagram  showing  changes 

in  shape  of  ...  008 

scolio-rhachitic       .         .         .         .662 

split 047 

spondylolisthetic  ....  * *« ' J -"> 
spondylolisthetic,    vertical    section 

through 004 

spondylolisthetic,     vertical     section 

through    sacrum    and    last    three 

lumbar  vertebras  of   .  .  .   000 

transversely  contracted  .  .646 

true  dwarf    .....   043 
Placenta  praevia,  diagram  illustrating 

Hofmcier's    theory   of   formation 

of 719 

diagram  showing  central  variety  .  717 
diagram     showing     marginal     and 

partial  variety    .  .  .  .    1 17 

foetus   partially    extracted    from    a 

patienl  dying  from,  showing  how 

it  acts  as  a  wedge  .  .  •  723 
in   which    no    attempt    at    delivery 

has  been  made  ....   718 
Placenta,    premature    separation    of, 

with  external  haemorrhage  .   714 

Posterior  parietal  presentation  .         .   620 

passage  through  superior  strait      .   020 


XX11 


OBSTETRICS 


Beni  form  superior  strait,  engagement 

of  head  in  .  .  .  .  .    G20 

Besuseitation     of     new-born     child, 

Sehultze's  method       .  .  .   752 

Bight    aeromio-iliae    dorso     anterior 

position,  diagram  showing  .  .   686 

Rupture    of    uterus,    frozen    section 

through  woman  dying  from         .    741 
Sacrum,  accentuation  of  vertical  con- 
cavity of,  in  rhachitis  .  .   604 
obliteration    of    vertical    concavity 
of,  in  rhachitis  ....   604 
Skull,  depression  of  .          .          .  .    625 
overlapping  of  bones  of,  seen  from 

above  .....   625 

overlapping  of  bones  of,  seen  from 

behind        .....   625 
spoon-shaped   fracture   of       .  .   626 

Spondylolisthesis,    fourth     and     fifth 

lumbar  vertebrae  from  case  of      .   666 
front  and  back  view  of  woman  with  667 
side   view    of   "woman   with,    show- 
ing projecting  spine  of  last  lum- 
bar vertebrae      ....   668 
Spontaneous    evolution,    diagram    il- 
lustrating mechanism  of     .  .   689 


Spontaneous     evolution,     rare     form 

of 690 

Transportation  of  chorionic  villus       .   701 

Section  VIII. — Pathology  of  the 

PUERPERIUM 

Doderlein's  tube  for  obtaining  uterine 

lochia  .....   784 

Endometritis,  puerperal,  due  to  colon 
bacillus,  leucocytic  wall  not  in- 
vaded by  bacteria       .  .  .   767 
due    to    colon    infection,    showing 
marked  development  of  leucocytic 

wall 766 

due  to  streptococcus,  showing  inva- 
sion of  leucocytic  wall  .  .   767 
due      to      streptococcus      infection, 
showing    slight    development    of 
leucocytic  wall            .          .          .   766 

Thrombosed  pelvic  vein,  due  to  strep- 
tococci       .  .  .  .  .769 

Uterus  from  woman  dying  from  strep- 
tococcus and  colon  infection        .   764 

Uterus  from  woman  dying  from  strep- 
tococcus infection        .  .  .765 


OBSTETRICS 


ANATOMY 

(  EAPTEE    I 

THE    PEL  VIS 

Historical. — As  the  mechanism  of  Labour  is  essentially  a  process  of 
accommodation  between  the  fcetus  and  the  passage  through  which  it  musl 

pass,  it  is  apparent  that  obstetrics  lacked  a  scientific  foundation  until 
the  anatomy  of  the  bony  pelvis  and  of  the  soft  part-  connected  with  it 
was  clearly  understood. 

We  are  indebted  to  Andreas  Vesalius  (15434  for  the  firsl  accurate  de- 
scription of  the  pelvis.  Prior  to  the  publication  of  his  observations  it 
had  generally  been  believed  that  the  birth  of  the  child  could  not  be 
effected  until  the  pelvic  cavity  had  become  increased  in  size  by  the  sepa- 
ration and  gaping  of  the  pelvic  bones.  Vesalius  demonstrated  the  fallacy 
of  this  conception,  and  showed  that  the  pelvis,  for  practical  purposes, 
should  be  considered  as  an  unyielding  bony  ring.  His  work  was  still  fur- 
ther elaborated  by  his  successor  at  the  University  of  Padua,  Realdus 
Columbus,  who  also  demonstrated  that  each  innominate  bone  was  origi- 
nally  composed  of  three  separate  portions:  the  ilium,  ischium,  ami  pubis, 
which  fused  together  just  before  the  age  of  puberty.  Julius  Caesar  Aran- 
tius,  Professor  of  Anatomy  in  Bologna  (1559).  also  made  important  con- 
tributions to  the  subject,  and  was  the  first  to  recognise  the  existence  of 
contracted  pelves. 

That  the  teachings  of  these  three  great  anatomists  ■! i«l  nn   exerl    - 
great  an  influence  as  might  have  been  expected,  was  largely  due  to  the  fact 
that  no  less  an  authority  than  Ambroise  Pare  still  continued  to  adhere  to 
the  doctrine  of  the  separation  of  the  pubic  bones  during  labour,  and  pro- 
mulgated it  in  his  obstetrical  writings. 

Among  obstetricians,  Heinrich  Deventer  was  the  first  to  make  a  thor- 
ough study  of  the  anatomy  of  the  pelvis.  In  his  New  Light  for  Mid- 
wives  (1T01)  he  dwelt  upon  it  in  detail,  and  also  described  the  main  vari- 
eties of  contracted  pelves.  At  that  time,  he  felt  called  upon  to  apologize 
for  taking  up  what  was  apparently  so  useless  a  consideration. 

Smellie  was  the  first  English  authority  to  devote  particular  attention 
to  the  subject.  In  his  work  on  midwifery,  published  in  1752,  lie  gave  a 
most  accurate  description  of  the  pelvis  and  its  various  measurements,  and 
also  introduced  the  method  of  determining  the  antero-posterior  diameter 
which  we  still  employ.  A  few  years  previously  (1735),  Johann  Huwe 
1  1 


2  OBSTETRICS 

had  gone  over  somewhat  the  same  ground,  but  his  work  had  not  re- 
ceived anything  like  the  consideration  which  was  accorded  to  Smellie's 
investigations. 

Almost  simultaneously  with  Smellie,  Levret,  the  great  French  obstet- 
rician, jmblished  the  results  of  his  observations,  and  was  one  of  the  first 
to  promulgate  the  conception  of  the  axis  and  the  planes  of  the  pelvis. 
The  value  of  his  work,  however,  was  considerably  impaired  by  many  inac- 
curacies. Among  the  Germans,  Stein  the  younger  was  apparently  the 
first  to  give  a  thoroughly  accurate  description  of  the  pelvis,  and  since  his 
time  correct  ideas  upon  the  subject  have  gradually  become  popularized. 
Practically,  therefore,  an  attempt  to  follow  the  further  development  of 
our  knowledge  concerning  the  pelvis  would  resolve  itself  into  writing  a 
history  of  obstetrics.  To  do  this  would  go  far  beyond  the  scope  of  the 
present  work;  and  let  it  here  suffice  to  say  that  among  the  more  modern 
authors  ISTaegele,  Luschka,  Michealis,  and  Litzmann  in  Germany,  and 
Hodge  in  this  country,  deserve  particular  mention. 

General  Considerations. — In  both  sexes  the  pelvis  forms  the  bony  ring 
through  which  the  body  weight  is  transmitted  to  the  lower  extremities,  but 


Fig.  1. — Normal  Female  Pelvis.     X  3. 


in  the  female  it  assumes  a  peculiar  form  which  adapts  it  to  the  purjDOses 
of  childbearing. 

It  is  composed  of  four  bones:  the  sacrum,  the  coccyx,  and  two  innomi- 
nate bones,  the  last  two  being  united  at  the  sacro-iliac  synchondroses  and 
the  symphysis  pubis  by  strong  articulations.  The  purely  anatomical  char- 
acteristics of  the  pelvis  are  dealt  with  at  length  in  the  standard  works  on 
anatomy,  and  more  especially  in  the  recent  text -book  of  Joessel  and  Wal- 
deyer,  so  that  we  shall  limit  our  considerations  to  the  peculiarities  of  the 
female  pelvis,  which  are  of  importance  in  childbearing. 

The  Pelvis  from  an  Obstetrical  Point  of  View. — The  linea  terminalis 
forms  the  boundary  between  the  false  and  the  true  pelvis,  the  former 


THE   PELVIS  :: 

lying  above  and  the  latter  below  it.  The  false  pelvis  is  bounded  posteriorly 
I > \_  the  lumbar  \cricl)i;i'  and  laterally  by  tKe  iliac  tossa?,  while  id  Eronl  the 
boundary  is  formed  by  the  lower  portion  of  the  anterior  abdominal  wall. 
Ii  possesses  no  particular  obstetrical  significance,  bul  serves  to  support  the 
intestines  in  the  non-pregnanl  woman*  and  the  enlarged  uterus  in  the 
pregnanl  condition,  h  varies  considerably  in  size  in  different  individuals, 
according  to  the  flare  of  the  iliac  bones;  hut  ordinarily  in  dried  speci- 
mens the  distances  betweeE  the  anterior  superior  spines  of  the  ilium  and 
between  the  most  widely  distanl  portions  of  the  iliac  crests  measure  33 
and  26  centimetres  respectively. 

Tin'  true  pelvis  lies  beneath  the  linen  terminalis,  and  is  the  portion 
concerned  in  childbearing.  It  is  bounded  above  by  the  promontory  and 
jil;v  of  the  sacrum,  the  linea  terminalis,  and  the  upper  margins  of  the  nubic 
hones,  and  below  by  the  polvic  out  let.  Its  cavity,  roughly  speaking,  may 
be  compared  to  an  obliquely  truncated  cylinder  with  its  greatest  heighl 
posteriorly,  since  its  anterior  wall  at  the  symphysis  pubis  measures  I.1,  to  ."> 
centimetres,  and  its  posterior  wall  lo  centimetres.  With  the  woman  in 
the  uprighl  position,  in  its  upper  portion  the  pelvic  canal  is  directed 
downward  and  backward,  while  in  its  lower  course  it  curves  and  becomes 
directed  downward  and  forward. 


The  walls  of  the  true  pelvis  are  partly  bony  and  partly  ligamentous. 

Its  posterior  boundary  is  furnished  by  the  anterior  surface  of  1 1 1  e__sauaLiii . 
its  lateral  limits  are  formed  posteriorly  by  the  saero-scia tie  notches  and 
ligaments,  and  anteriorly  by  the  inner  surface  of  the  ischial  bones;  while 
in  front  it  is  bounded  by  the  obturator  foramina,  the  pjibicTboncs,  and 
the  ascending  rami  of  the  ischial  honest 

The  only  part  of  the  lateral  wall  of  the  pelvis  which  is  entirely  bony  is 
made  up  of  part  of  the  ischium,  the  inner  surface  of  which,  with  the 
woman  in  the  upright  position,  forms  an  inclined  plane  which  is  directed 
from  above  downward  and  inward,  and  from  behind  forward.  Consider- 
able importance  was  attached  to  these  surfaces  by  Hodge,  who  designated 
them  as  the  inclined  planes  of  the  pelvis,  and  considered  that  they  exer- 
cised a  good  deal  of  influence  in  causing  internal  rotation  of  the  head  dur- 
ing labour.  This  view,  however,  has  since  been  abandoned.  If  the  planes 
of  the  ischial  bones  were  extended  downward  they  would  meet  somewhere 
about  the  region  of  the  knee._  Extending  from  the  middle  of  the  pos- 
terior margin  of  each  ischium  are  the  ischial  spines,  which  are  of  no 
little  obstetrical  importance,  inasmuch  as  a  line  drawn  between  them  rep- 
resents the  shortest  diameter  of  the  pelvic  cavity.  .Moreover,  since  they 
can  be  readily  felt  on  vaginal  examination,  they  tan  be  made  to  serve  as 
valuable  landmarks  in  determining  the  extent  to  which  the  presenting  part 
has  descended  into  the  pelvis. 

The  sacrum  forms  the  posterior  wall  of  the  pelvic  cavity.  Its  upper 
anterior  portion,  corresponding  to  the  body  of  the  first  sacral  vertebra, 
and  designated  as  the  promontory,  can  be  felt  on  vaginal  examination,  and 
offers  a  landmark  which  serves  as  the  basis  of  internal  pelvimetry.  Nor- 
mally, the  sacrum  presents  a  marked  vertical  and  a  less  pronounced  lateral 
concavit}r,  which,  in  abnormal  pelves,  may  undergo  variations.     A  straight 


OBSTETRICS 


Fig.  2. — Drawing  showing  that  the  Sacrum  is  not  the 

Keystone  of  the  Arch. 

Modified  from  Duncan.     X  £■ 


line  drawn  from  the  promontory  to  the  tip  of  the  sacrum  usually  meas- 
ures 10  centimetres,  whereas  if  the  concavity  he  followed  the  distance 
averages  12  centimetres. 
The  sacrum  was  formerly 
regarded  as  the  "  key- 
stone "  of  the  pelvic  arch, 
but  Matthews  Duncan 
showed  that  this  concep- 
tion was  erroneous,  and 
that  it  represents  an  in- 
verted keystone,  inasmuch 
as  it  is  wider  along  its  an- 
terior than  along  its  pos- 
terior surface,  so  that  it 
would  tend  to  slip  down- 
ward and  forward  into  the 
pelvic  cavity  under  the  in- 
fluence of  the  body  weight 
were  it  not  held  in  po- 
sition by  the  strong  pos- 
terior ilio-sacral  ligaments 
(Fig.  2).  * 

In  the  female  the  pubic  arch  presents  a  characteristic  appearance.    The 
descending  rami  of  the  pubis  unite  at  an  angle  of  90  to  100  degrees,  and 

form  a  rounded  opening  through 
which  the  head  can  readily  pass.  Its 
margins  are  more  delicate  than  in  the 
male,  and  are  considerably  everted. 

Planes  and  Diameters  of  the  Pelvis. 
— Owing  to  the  peculiar  shape  of  the 
pelvic  cavity  and  the  difficulty  experi- 
enced in  rendering  clear  the  exact 
location  of  a  body  occupying  it,  for 
greater  convenience  in  description  it 
is  customary  to  construct  certain  im- 
aginary planes  through  it.  Those  most 
frequently  employed  are  designated  as 
(1)  the  superior  strait,  (2)  the  inferior 
strait,  (3)  the  plane  of  greatest,  and 
(4)  the  plane  of  least,  pelvic  dimen- 
sions (Figs.  3  and  5). 

The  superior  strait 
represents  the  upper 
boundary  of  the  cav- 
ity, and  is  frequently 
spoken  of  as  the  pelvic 
inlet.  It  is  somewhat  oval  in  shape,  with  a  depression  on  its  posterior  bor- 
der corresponding  to  the  promontory  of  the  sacrum,  and  is  occasionally  de- 


,tif> 


Tig.  3. — Sagittal  Section  through  Normal  Pelvis.     X  \. 


THE   PELVIS 

scribed  as  Muni  heart-shaped.  It  is  bounded  posteriorly  by  the  promon- 
tory and  ahr  of  the  sacrum;  laterally  by  the  Linea  terminalis;  anteriorly  by 
the  horizontal  rami  of  the  pubic  bones  and  the  symphysis  pubis.  Strictly 
speaking,  it  is  nol  a  mathematical  plane,  since  its  lateral  margins,  as  repre- 
sented by  tin-  linea  terminalis,  are  al  a  lower  level  than  its  central  portion 
between  the  promontory  and  symphysis  pubis. 


Fig.  4. — Normal  Female  Pelvis  showing  Diameters  of  the  Superior  Strait.     X  J. 


Four  diameters  are  usually  described  as  traversing  the  superior  strait: 
the  antero-posterior,  the  transverse,  and  two  oblique  diameters.  The  an- 
teroposterior diameter  extends  from  the  middle  of  the  promontory  of  the 
sacrum  to  the  upper  margin  of  the  symphysis  pubis,  and  is  designated  as  the 
coiijuf/atn  rem  or  imp  mn'utaaip.  This  term  was  first  employed  by  Roe- 
derer,  who  likened  the  superior  strait  to  an  ellipse,  whose  shorter  diameter 
ran  antero-posteriorky.  Normally,  the  conjugata  vera  measures  11  centi- 
metres, but  it  may.  become  markedly  shortened  in  abnormal  pelves.  From 
a  practical  point  of  view  it  is  the  most  important  diameter,  inasmuch  a> 
it  is  the  point  of  departure  for  all  attempts  to  estimate  the  size  of  the 
pelvis  in  actual  practice.  The  transverse  diameter  is  constructed  at  right 
angles  to  the  conjugata  vera,  and  represents  the  greatest  distance  between 
the  linea  terminalis  on  either  side;  it  usually  intersects  the  conjugata  vera 
at  a  point  a  short  distance  in  front  of  the  promontory.  Normally  it  measures 
13.5  centimetres.  Each  of  the  oblique  diameters  extends  from  one  of  the 
sacro-iliac  synchondroses  to  the  ilio-pectineal  eminence  on  the  opposite 
side  of  the  pelvis.  They  measure  12.75  centimetres,  and  are  designated  as 
right  and  left  respectively,  according  as  the  starting-point  is  the  right 
or  left  sacro-iliac  synchondrosis.  Instead  of  employing  the  terms  right 
and  left,  the  Germans  usually  speak  of  the  first  and  second  oblique  diam- 
eters. The  sacro-cotvloid  diameters  are  sometimes  described;  they  ex- 
tend from  the  middle  of  the  promontory  of  the  sacrum  to  _the  ilio-pec- 
tineal eminence  on  either  side,  and  measure  from  8.75  to  9  centimetres. 


6 


OBSTETRICS 


Normally  these  two  diameters  are  of  equal  lengthy  but  in  certain  forms  of 
contracted  pelves  they  may  present  marked  variations. 

The  antero-posterior  diameter  of  the  superior  strait  is  frequently 
described  as  the  a n atomical  conjugate  or  the  conjugata  vera.  This  does 
not  represent  the  shortest  distance  between  the  promontory  of  the  sacrum 
and  symphysis  pubis,  which  is  along  a  line  drawn  from  the  former  to  a 
point  on  the  inner  surface  of  the  symphysis  a  few  millimetres  below  its 
upper  margin.  The  latter  is  the  shortest  diameter  through  which  the 
head  must  pass  in  descending  into  the  superior  strait,  and  was  designated 
by  Michealis  as  the  obstetrical  con  jugate.  It  is  a  few  millimetres  shorter 
than  the  anatomical  or  true  conjugate,  but  for  practical  purposes  the  dis- 
tinction is  rarely  made,  and  the  obstetrician  simply  speaks  of  the  con- 
jugata vera. 

Unfortunately,  in  the  living  woman,  the  conjugata  vera  cannot  be  meas- 
ured directly  with  the  examining  finger,  and  various  more  or  less  compli- 
cated instruments  have  been  devised  for  its  determination,  only  a  few  of 


Fig.  5. — Diagram  showing  Pelvic  Planes.     X  i- 


which  give  satisfactory  results.  For  clinical  purposes,  therefore,  we  are 
content  to  estimate  its  length  indirectly,  by  measuring  the  distance  from 
the  lower  margin  of  the  symphysis  to  the  promontory  of  the  sacrum,  and 
subtracting  from  the  result  1.5  to  2  centimetres,  according  to  the  height 
and  inclination  of  the  symphysis  puois~  Tfris  diameter  is  the  conjugata 
diaqonalis  or  oblique  conjugate,  the  importance  of  which  was  first  empha- 
sized by  Smellie. 

The  outlet  of  the  pelvis  is  designated  the  inferior  strait.  It  is  not 
a  plane  in  a  mathematical  sense,  but  consists  of  two  triangular  planes 
whose  bases  would  meet  on  a  line  drawn  between  the  two  ischial  tuber- 
osities. It  is  bounded  posteriorly  by  the  4ig,  of  the  coccyx,  laterally  by  the 
greater  sacro-sciatic  ligaments  and  the  ischiaT"tUbei'6atties,  and  anteriorly 
by  the  lower  margin  of  the  pubic  arch  (Fig.  6).     For  the  pelvic  outlet 


THE    PELVIS 


two  diameters  .nv  described:  the  ,iiilcro-|)oslci-ior  and  the  transver-c  The 
former  extends  from  the  lower  margin  of  (he  symphysis  pubis  l«»  the  tip 
of  the  coccyx,  and  the  latter  between   the  inner  margins  of  Hi''  ischial 


Fig.  6. — Pelvic  Outlet.     X  i. 

tuberosities.  With  the  coccyx  in  its  normal  position,  the  antero-posterior 
diameter  measures  9.5  centimetres,  which  is  increased  to  11.5  centimetres 
during  labour  by  the  backward  displacement  of  the  tip  of  the  coccyx.  The 
transverse  diameter  measures  11  centimetres. 

The  plane  of  greatest  pelvic  dimensions  was  first  described  by  Levret, 
and,  as  its  name  implies,  represents  the  roomiest  portion  of  the  pelvic 
cavity.     It  extends  from  the  middle  of  the  posterior  surface  of  the  sym- 


Pubis 


Rectus- 


Symphysis 


\SV  Obturator 

'^Xforamen 


Promontory 
Fig.  7. — Superior  Strait  (Veit) 


Sacrum 

Fig.  8. — Plane  of  Greatest  Dimensions. 


physis  pubis  to  the  junction  of  the  second  and  third  sacral  vertebrae, 
and  laterally  passes  th'rougn  me  iscnial  bonej  over  the  middle  oi  the  ace- 
tabulum. Its  antero-posterior  and  transverse  diameters  measure  12.75  and 
12.5  centimetres  respectively.     Since  its  oblique  diameters  terminate  in 


OBSTETRICS 


the  obturator  foramina  and  the  sacro-sciatic  notches,  they  are  subject  to 
marked  variations  in  length. 

The  plane  of  least  pelvic  dimensions  extends  through  the  lower  mar- 
gin of  the  symphysis  pubis,  the  tip  of  the  sacrum,  and  the  ischial  spines. 
Its  antero-posterior  diameter  measures  11.5  and  its  transverse  diameter 
10.5  centimetres,  the  latter  being  the  shortest  diameter  in  the  normal 
pelvic  cavity. 

Hodge  designated  as  the  second  parallel,  another  plane  which  passes 
through  the  lower  margin  of  the  symphysis  pubis  parallel  to  the  plane 
of  the  superior  strait.  Vrery"closely  related  to  it  is  that  described  by  Yeii- 
as  the  mam  plane  of  the  pelvis,  which  extends  from  the  lower  margin  of 
the  symphysis  pubis  to  the  junction  of  the  first  and  second  sacral  verte- 
bras.  According  to  A^eit  this,  from  an  obstetrical  stand-point,  is  the  largest 
plane  of  the  pelvis,  inasmuch  as  it  is  not  encroached  upon  by  the  pelvic 


Pubic  ramus 


Pubic  ramus 


/  Obturator  interims  \\ 

1 


Tip  of  Sacrum 

Fig.  9. — Plane  of  Least  Dimensions  (Veit). 


Ilium 
p^\Ischium     I'HIMI  Iliopsoas 


oacruih. 

Fig.  10. — Veit's  Main  Plane. 


soft  parts,  but  passes  above  the  obturator  and  pyriformis  and  below  the 
ilio-psoas  muscles. 

Most  pelves  present  slight  individual  variations  in  size,  and  perfectly 
normal  and  symmetrical  examples  are  rarely  seen.  The  measurements 
which  we  have  given  are  those  of  Schroeder,  and  are  the  averages  obtained 
from  the  accurate  mensuration  of  50  normal  pelves. 

Pelvic  Inclination. — The  normal  position  of  the  pelvis,  with  the 
woman  in  the  erect  posture,  can  be  reproduced  by  holding  the  specimen 
in  such  a  way  that  the  incisions  of  the  acetabula  look\directly  downward. 
According  to  Meyer,  the  pelvis  is  in  its  normal__piisi ti  an  when  the  ^ante- 
rior superior  spines  of  the  ilium  and  the  pubic  spines  are  in  the  sanie" 
vertical  plane.  Under  these  conditions  the  promontory  of  the  sacrum 
is  9.5  to  10  centimetres  higher  than  the  upper  margin  of  the  sym- 
physis pubis. 

By  the  term  pelvic  inclination  we  understand  the  angle  which  the  plane 
of  the  superior  strait  forms  with  the  horizon  (see  Fig.  3).  This  conception 
was  first  introduced  by  J.  J.  Miiller  and  Eoederer,  and  the  early  state- 
ments  concerning  it   were   very   conflicting.      According   to   Meyer,   the 


THE    PELVIS  9 

centre  of  gravity  of  the  body  passes  along  an  imaginary  vertical  plain-  just 
posterior  to  the  acetabular  so  thai  under  the  influence  of  the  body  weighl 
the  pelvis  would  tend  to  rotate  backward  were  ii  no1  held  in  position  by 
the  strong  ilio-femoral  Ligaments.  Ii  is  therefore  appareni  thai  the  pelvic 
inclination  tnusl  vary  according  to  the  degree  of  tension  of  these  struc- 
tures; ii  will  lie  diminished  when  they  are  relaxed,  and  vice  versa.  Ii  is 
leas!  marked  when  the  iegs  arc  slightly  rotated  inward  and  spread  a  iittle 
apart,  and  markedly  increased  when  the  knees  are  pressed  tightly  to- 
gether, or  when  the  legs  are  widely  spread  apart  or  rotated  strongly 
either  inward  or  outward.  With  the  woman  in  the  uprighi  position 
the  pelvic  inclination  is  usually  estimated  at  L-5  to  50  degrees,  bul  may 
vary  from  40  to  100  degrees  according  to  the  degree  of  tension  exerted  by 
the  ilio-femoral  ligaments.  In  certain  diseased  conditions  it  may  be  oblit- 
erated, and  the  plane  of  the  superior  strait  may  become  parallel  to  the 
horizon. 

The  first  accurate  work  upon  this  subject  was  done  by  Naegele,  who 
measured  the  distance  from  the  floor  to  the  lower  margin  of  the  symphysis 
pubis  and  the  tip  of  the  sacrum  respectively,  and  in  this  way  estimated 
the  inclination  which  the  inferior  strait  formed  with  the  horizon.  He 
then  placed  a  normal  pelvis  in  a  similar  position  and  estimated  the  in- 
clination of  its  superior  strait,  which  was  usually  about  60  degrees. 

In  view  of  the  marked  variations  to  which  the  pelvic  inclination  is 
subject,  Meyer  introduced  a  newr  conception  concerning  it,  and  stand 
that  it  was  considerably  influenced  by  the  extent  to  which  the  sacrum  ro- 
tated about  its  transverse  axis.  As  this  passes  through  the  centre  of  the 
body  of  the  third  sacral  vertebra,  it  is  apparent  that  this  portion  of  the 
sacrum  retains  approximately  the  same  position,  no  matter  to  what  ex- 
tent its  upper  or  lower  portions  may  be  displaced.  Meyer,  therefore,  con- 
structed a  diameter  extending  from  the  upper  margin  of  the  symphyses  to 
the  middle  of  the  third  sacral  vertebra,  and  designated  it  the  normal  cotir 
jugate.  Its  inclination  he  estimated  at  30  degrees,  and  stated  that  it  re- 
mained, practically  constant  in  all  positions  of  the  body. 

Except  when  markedly  abnormal,  the  pelvic  inclination  possesses  no 
practical  obstetrical  significance,  and  is  of  value  only  in  the  study  of 
atypical  pelves  and  anthropology.  Several  complicated  instruments  have 
been  invented  for  determining  it,  but  Prochownick  has  suggested  that  it 
may  be  approximately  estimated  by  drawing  a  line  from  the  spine  of  the 
last  lumbar  vertebra  to  the  upper  margin  of  the  symphysis,  and  estimating 
the  angle  which  this  forms  with  the  horizon. 

Since  the  lower  margin  of  the  symphysis  occupies  a  lower  level  than 
the  tip  of  the  sacrum,  the  plane  of  the  inferior  strait  is  also  inclined  to 
the  horizon,  forming  an  acute  angle,  which  is  usually  estimated  at  JJ)  de- 
grees. Much  more  important,  however,  is  the  angle  which  is  formed  be- 
tween the  posterior  surface  of  the  symphysis  pubis  and  the  conjugata  vera: 
this  is  usually  estimated  at  90  to  100  degrees,  but  varies  considerably 
according  to  the  shape,  height,  and  inclination  of  the  symphysis  pubis. 
It  must  always  be  taken  into  consideration  in  estimating  the  length  of  the 
conjugata  vera  from  that  of  the  conjugata  diagonalis,  since  it  is  evident 


10 


OBSTETRICS 


that  the  amount  to  he  subtracted  from  the  latter  will  vary  with  the  size 
of  the  angle  between  the  symphysis  and  the  conjugata  vera. 

The  Pelvic  Axis. — Deventer  introduced  the  conception  of  a  pelvic  axis, 
which  he  obtained  by  erecting  perpendiculars  at  the  centres  of  innumer- 
able planes,  extending  from  the  symphysis  to  the  sacrum  (see  Fig.  3).  At 
the  end  of  pregnancy  the  axis  of  the  superior  strait,  if  extended  directly 
upward,  would  pass  through  the  abdominal  wall  at  about  the  region  of  the 
umbilicus,  while  the  axis  of  the  inferior  strait  would  impinge  upon  the 
promontory  of  the  sacrum.  The  direction  of  the  pelvic  axis,  therefore, 
would  follow  a  curved  line,  which  was  formerly  believed  to  represent  the 
course  which  the  child  pursued  in  its  passage  through  the  pelvis.  The 
work  of  Naegele,  Hegar,  Pinard,  and  others,  however,  has  shown  that  this 
is  not  the  case,  so  that  at  present  this  axis  possesses  only  an  historical 
interest. 

The  Pelvic  Joints. — Anteriorly  the  pelvic  bones  are  held  together  by 
the  symphysis  pubis,  which  consists  of  a  mass  of  fibro-cartilage,  and  by 

the    superior   and   inferior   pu- 


Superior  Pubic  Lis*. 


v&: 


Fibro-cartilag'e 


Li?. 

Arcuatura 
Pubis 


Fig.  11- 


superior 
bic  ligaments,  the  latter  being 
frequently  designated  as  the 
ligamentnm  arcuatum  pubis. 
Luschka  demonstrated  the  pres- 
ence of  a  synovial  cavity  in  the 
fibro  -  cartilage,  and  therefore 
classed  the  symphysis  among  the 
true  joints  (Fig.  11).  Joessel, 
on  the  other  hand,  denies  its 
existence,  and  states  that  the 
fluid  in  the  interior  of  the  sym- 
physis is  simply  a  product  of  de- 
generation. Whether  it  be  a 
true  joint  or  not,  in  any  case 
the  symphysis  admits  of  a  cer- 
tain amount  of  motility,  which 
becomes  particularly  marked 
during  pregnancy.  This  fact  was  demonstrated  by  Budin,  who  showed  that 
if  the  finger  were  inserted  into  the  vagina  of  a  pregnant  woman,  and  she 
were  made  to  walk,  one  could  distinctly  feel  the  ends  of  the  pubic  bones 
move  up  and  down  with  each  stej). 

The  articulations  between  the  sacrum  and  innominate  bones  were  for- 
merly described  as  synchondroses,  but  Luschka  conclusively  demonstrated 
the  presence  of  a  synovial  cavity  within  them,  and  therefore  classed  them 
among  the  true  joints  (Fig.  ~t2).  These  articulations  possess  a  certain 
amount  of  motility  which  plays  a  not  unimportant  part  in  practical  ob- 
stetrics. 

Watcher,  in  1889,  stated  that  the  diagonal  conjugate  varied  about  1 
centimetre  in  length,  according  as  it  was  measured  with  the  woman  in  the 
usual  obstetrical  position,  or  with  her  buttocks  resting  on  the  edge  of  the 
table  and  her  legs  hanging  down  without  any  support,  which  has  since 


-Frontal  Section  Symphysis  Pubis 
(Spalteholz).     X  1. 


THE   PELVIS 


11 


r  Hanging 

wIid  have 

Lie  and 

ml>  jecl 


posil  ion.     1 1  is  observal  ions  have 
repeated  his  work,  among  whom 


Post.  Sacro-iliac  Li(f. 


Interosseous  Liff. 
Articular  cavity 
V\nt.  Sacroiliac  Licj. 


12. — Saoro-iliao  Synchondrosis 
(Spalteholz).    X  1. 


been  known  as  the  Walcher 
been  confirmed  by  nearly  a] 
may  be  mentioned  Klein,  W 
Leopold  and  Kiittner.  Th< 
was  chosen  as  one  of  i be  main  i hemes 
for  discussion  at  the  International 
Gynaecological  and  Obstetrical  Con- 
gress held  at  Amsterdam  in  L899. 
The  speakers,  almost  without  excep- 
i  ion,  admitted  the  general  correct  ness 
of    Walcher's    statements,    differing 


only  as  to  the  extent  of  the  changes, 
while  Bar  was  the  only  one  to  deny 
t heir  occurrence. 

This  slight  amount  of  motility  is 
utilized  in  dealing  with  contracted 
pelves;  and  not  infrequently  the  in- 
crease** in  the  size  of  the  conjugata 
vera,  brought  about  by  Walcher's  posi- 
tion, has  proved  sufficient  to  permit  the  engagement  of  the  presenting  pan. 
which  otherwise  could  not  occur.  The  effect  of  Walcher's  position  upon 
the  size  of  the  pelvic  cavity  has  recently  been  studied  very  carefully  by 
Kiittner,  who  showed  in  three  cases  that  the  conjugata  vera  was  respectively 

1.4,  0.9,  and  1  centimetre  longer 
when  measured  in  the  hanging 
than  in  the  lithotomy  position. 
Fig.  13  gives  a  graphic  illustration 
of  the  changes  in  shape  in  one  of 
these  pelves. 

Methods  of  Comparing  Pelves. 
- — Inasmuch  as  the  normal  pelvis 
usually  presents  slight  individual 
variations  in  its  form  and  dimen- 
sions, and  as  contracted  pelves  dif- 
fer markedly  from  one  another  in 
shape,  several  devices  have  been 
employed  to  enable  us  to  readily 
compare  their  points  of  difference. 
The  decimal  method,  suggested  by 
Litzmann,  is  very  satisfactory  for 
most  purposes.  In  it  the  various  diameters  are  expressed  in  terms  of  the 
conjugata  vera,  which  is  reckoned  as  1 00,  ( see  table  on  the  following  page). 
Breisky  introduced  a  graphic  method  for  comparing  pelves  and  con- 
structed three  diagrams,  representing  a  vertical  mesial  section  of  the  pel- 
vis, the  plane  of  the  superior  strait,  and  a  frontal  view  of  the  pelvis.  The 
first  is  constructed  upon  Meyer's  normal  conjugate,  the  second  upon  the 
distance  between  the  sacro-iliac  synchondroses,  and  the  third  upon  the 
transverse  diameter  of  the  pelvic  outlet. 


Fig.  13. — Diagram  showing  Variation  of  An- 
tero  -  posterior  dlajieter  of  pelvis  in 
Various  Positions  (Kiittner).     X  J. 

A,  lithotomy  ;  B,  horizontal ;  C,  Walcher's  position. 


12 


OBSTETRICS 


Comparison  of  Various  Diameters  of 
Normal  Pelvis  by  Litzmann's  Deci- 
mal Method. 

diameters. 

Antero-posterior. 

Transverse. 

Oblique. 

100 
115 
105.5 
105.5 

122 . 7 
113.6 
95.5 
100 

113 

Plane  of  greatest  pelvic  dimension. 
Plane  of  least  pelvic  dimension..  . . 

Individual  Variations  in  the  Pelvis. — With  the  exception  of  the  skull, 
no  portion  of  the  skeleton  presents  greater  individual  variations  than  the 
pelvis.  This  is  due  partly  to  the  fact  that  it  is  developed  from  a  consider- 
able number  of  bones,  and  partly  to  the  varying  mechanical  and  devel- 
opmental influences  to  which  it  is  subjected  during  the  early  years  of  life. 

Sp.  Sp. 


s. 

Fig.  15. 

Figs.  14-16. — Breisky's  Diagrams  for  Comparing  Pelves. 
I.,  inclination  of  iliac  bones ;  LP.,  ilio-pectincal  eminence ;  P.,  promontory  of  sacrum  ;  S.,  upper 
margin    of  symphysis;  S.1,  lower  margin  of  symphysis;  S.I.,  sacroiliac  synchondrosis;  Sp., 
iliac  spines  ;   T.,  transverse  diameter,   superior  strait ;  T.I.,  tuber  ischii ;   3,  bend  in  body  of 
third  sacral  vertebra. 

Indeed,  we  may  say  that  no  two  pelves  are  exactly  alike,  and  that  per- 
fectly normal  pelves  are  rarely  seen;  so  that  an  accurate  conception  of  the 
form  and  dimensions  of  what  may  be  termed  the  normal  type  can  be 
obtained  only  from  averages  based  upon  the  examination  of  numerous 
approximately  normal  pelves. 

Owing  to  the  greater  employment  of  the  right  half  of  the  body,  the 
corresponding  side  of  the  pelvis  is  more  developed  than  the  left.  Indi- 
vidual variations  may  be  observed  in  the  form,  consistence,  and  general 
character  of  the  pelvic  bones,  in  the  angles  which  the  iliac  fossas  form  with 
the  walls  of  the  pelvic  basin,  in  the  shape  of  the  sacrum,  and  particularly 
in  that  of  the  cavity  itself.  In  view,  therefore,  of  the  varying  thickness  of 
the  pelvic  bones,  and  especially  of  the  degree  of  flaring  of  the  ilia,  accurate 
conclusions  cannot  be  based  upon  external  pelvimetry. 


THE    PELVIS 


l:: 


Sexual  Differences  in  the  Adult  Pelvis.-  The  pelvis  presents  marked 

sexual  differences.     Speaking  generally,  we  may  say  that    in   (lie  male  the 
pelvis  is  heavier,  higher.  Less  graceful  than  in  the  Eemale,  and  presents  a 


\^y 


Fig.  17. — Front  View  Female  Pelvis.     X  i. 

more  conical  appearance.  In  the  male  the  muscular  attachments  are  much 
more  strongly  marked,  and.  the  iliac  bones  are  less  flared  than  in  the 
female.  The  pubic  arch  is  more  angular  in  shape,  and  presents  an  aper- 
ture of  70  to  75  degrees,  as  compared  to  90  to  100  degrees  in  the  female. 


Fig.  18. — Froxt  View  Male  Pelvis.     X  $• 


This  difference  is  so  marked  that  one  usually  speaks  of  the  pubic  angle 
in  the  male  and  the  pubic  arch  in  the  female.  In  the  male  pelvis  the 
superior  strait  is  smaller  and  more  triangular  in  outline,  while  the  pelvic 
cavity  is  deeper  and  more  conical  in  shape.    These  differences  are  readily 


14 


OBSTETRICS 


noted  in  Figs.  17,  18,  and  19,  and  may  be  especially  emphasized  by  a  com- 
parison of  the  various  measurements  in  the  two  sexes. 

Broadly  speaking,  the  external  measurements  are  practically  alike  in 
both  sexes,  though  the  distance  between  the  anterior  superior  spines  of 


Fig.  19. — Diagram  showing  Difference  in  Shape  of  Male  [....]  and  Female  [ J  Pelvis. 

the  ilium  is  somewhat  less  in  the  male;  while  all  the  diameters  of  the  pelvic 
cavity  are  shorter,  as  is  shown  by  the  following  table: 


Comparison  of  Male  and  Female 

DIAMETERS. 

Pelvis. 

Antero-posterior. 

Transverse. 

Oblique. 

Superior  strait : 

Male 

10.5 

11 

9.5 
11.5 

12.5 
13.5 

8  cm. 
11  cm. 

12  cm. 

Inferior  strait : 

Male 

12.75  cm. 

THE   l'Kl.\  [S  L5 

It  is  therefore  apparent  thai  the  outlel  of  the  male  pelvis  is  con- 
tracted to  such  a  degree  as  to  render  ii  impossible  for  a  living  child  to 
pass  through  it,  particularly  in  being  forced  out  under  the  pubic  angle. 
Occasionally  the  female  pelvis  may  approach  the  male  type,  and  under  such 
circumstances  may  offer  insuperable  obstacles  to  the  birth  of  the  child,  and 
necessitate  radical  operative  procedures  to  effecl  delivery. 

Numerous  ao1  very  satisfactory  attempts  have  been  made  to  explain 
the  cause  of  the  differences  between  the  male  and  female  pelvis.  Accord- 
ing to  Fehling  and  most  subsequent  investigators,  sexual  differences  make 
their  appearance  as  early  as  the  j\mrt_h  or  liftli  immil|  of  intra-uterine 
life,  so  that  the  sex  can  be  ascertained  long  before  term  by  examination  of 
the  pelvis.  Arthur  Thompson  has  recently  made  the  same  statement,  and 
my  own  investigations  have  led  me  to  similar  conclusions.  <>n  the  other 
hand.  Schroeder  and  other  authorities  attribute  the  characteristic  shape 
of  the  female  pelvis  to  the  presence  of  the  internal  genitalia,  and  state  that 
the  pelves  of  female  eunuchs,  as  well  as  those  of  individuals  in  whom  the 
uterus  is  congenitally  absent,  conform  to  the  male  type.  While  the  cor- 
rectness of  such  statements  cannot  be  doubted,  it  nevertheless  seems 
probable  that  the  greater  part  of  the  sexual  differences  must  be  due  to 
inherent  developmental  and  hereditary  factors. 

Racial  Differences. — Considerable  variations  may  be  observed  in  the 
form  of  the  pelvis  in  various  races,  and  especially  upon  comparing  those 
obtained  from  aboriginal  and  civilized  peoples.  But  in  spite  of  the  re- 
searches of  Weber,  Stein,  Yerneau,  Topinard,  Turner,  and  others,  our 
knowledge  upon  the  subject  is  still  fragmentary.  Stein  distinguished  four 
groups  of  pelves: 

1.  Blunt  heart-shaped. 

2.  Elliptical,  with  the  greatest  diameter  transverse. 

3.  Bound. 

4.  Elliptical,  with  the  greatest  diameter  antero-posterior. 
Topinard   attempted   to   classify   pelves   according  to   their   "  general 

index'' — that  is,  the  relation  between  their  height  and  width,  as  repre- 
sented by  the  distance  between  the  iliac  crests.  His  careful  measurements 
showed  that  the  pelvis  becomes  increasingly  lower  and  broader  the  more 
civilized  the  race  from  which  it  is  obtained. 

Turner  based  his  classification  upon  the  relation  between  the  transverse 
and  antero-posterior  diameters  of  the  superior  strait,  and  divided  pelves 
into  three  great  groups:  doliebopellie.  in  which  the  conjugata  vera  is 
greater  than  the  transverse  diameter;  mesatipellic.  in  which  the  conjugata 
vera  and  transverse  diameters  are  of  equal  length:  and  platypellic,  in  which 
the  conjugata  vera  is  shorter  than  the  transverse  diameter.  lie  stated  that 
the  first  variety  had  not  been  observed  in  women,  though  it  is  not  infrequent 
in  men.  The  mesatipellic  variety  is  observed  in  the  women  of  the  lower 
races,  notably  among  the  Bushmen,  Hottentots,  and  the  lower  classes  of 
negroes;  while  the  platypellic  forms  are  found  in  all  the  higher  races.  But 
even  among  civilized  whites  considerable  racial  differences  are  not  infre- 
quently noted,  and  it  is  generally  stated  that  the  pelves  of  the  English  and 
Holstein  women  are  broader  than  those  of  other  nationalities:  while  the 


16 


OBSTETRICS 


Fig.  20. — Sagittal  Section  showing  Relative 
Proportion  of  Bone  and  Cartilage  in 
the  Pelvis  of  a  Newly  Born  Child.     X  1. 


Jewesses  living  in  the  vicinity  of 
Dorpat  have  extremely  small 
pelves. 

While  the  study  of  the  racial 
differences  in  the  pelvis  presents  a 
marked  anthropological  interest, 
it  is,  as  yet,  of  little  practical  ob- 
stetrical value,  as  no  extended 
studies  have  been  made  concerning 
the  form  and  size  of  the  heads  of 
children  which  are  born  through 
them.  My  own  experience  in  Bal- 
timore has  shown  that  contract- 
ed pelves  occur  several  times 
more  frequently  among  black  than 
white  women  (21  per  cent  to  7 
per  cent),  while  ojDerative  deliv- 
ery is  more  frequently  required 
among  the  latter.  This  is  prob- 
ably due  to  the  fact  that  the  heads 
of  negro  children  are  somewhat 
smaller  and  more  compressible, 
and  thus  compensate  for  the 
smaller  size  of  the  pelvis. 
Pelvis  of  the  New-born  Child. — The  pelvis  of  the  child  at  birth  is  partly 
bony  and  partly  cartilaginous.  The  innominate  bone  does  not  exist  as  such, 
its  place  being  taken  by  the  ilium,  ischium,  and  pubis,  which  are  united  by 
a  large  Y-shaped  cartilage,  the  three 
bones  meeting  in  the  acetabulum. 
The  iliac  crests  and  the  acetabula,  as 
well  as  the  greater  part  of  the  ischio- 
pubic  rami,  are  entirely  cartilaginous 
in  structure.  Figs.  20  and  21  clearly 
show  the  extent  to  which  the  infan- 
tile pelvis  is  ossified. 

The  cartilaginous  portions  of  the 
pelvis  gradually  give  place  to  bone, 
but  complete  union  in  the  neigh- 
bourhood of  the  acetabulum  does  not 
occur  until  about  the  age  of  puberty, 
and  occasionally  even  at  a  later  pe- 
riod.  Indeed,  we  may  say  that  the 
innominate  bones  do  not  become 
completely  ossified  and  fully  devel- 
oped until  between  the  twentieth 
and  twenty-fifth  years. 

Each  innominate  bone  is  devel- 
oped from  12  centres  of  ossification.. 


Fig.  21. — Section  through  Infantile  Pelvis 
Parallel  to  Superior  Strait,  showing 
Relative  Proportions  of  Bone  and  Car- 
tilage.    X  1. 

A.,  acetabulum  ;  J.,  ilium;  P.,  pubic  "bone  ;  8., 
symphysis  pubis ;  S.A.,  ala  of  sacrum ; 
S.B.,  body  of  sacrum  ;  V.A.,  vertebral  arch. 


THE    PELVIS 


IT 


22. — Disarticulated   Pelvis  of  Three- 
year-old  Girl.     X  i- 


Three  of  these  are  primary  and  give  rise  to  the  ilium,  ischium,  and  pubis. 
They  make  their  appearance  by  the  end  of  the  first  half  of  pregnancy.  The 
remaining  9  centres — the  so-called  epiphyseal  ci-iiiivs — an-  -rcomlarv.  and 
do  not  develop  until  a  considerably  later  period,  some  of  them  no1  until 
after  the  age  of  puberty. 

The  sacrum  at  birth  is  Likewise  partly  bony  and  partly  cartilaginous. 
It  is  made  up  of  21  distinct  hones,  each  of  which  is  derived  from  a  single 
centre  of  ossification.  The  2  1  centres 
are  arranged  as  follows:  1  for  each 
vertebral  body  (5);  3  for  the  alse  on 
either  side  (6);  and  2  for  the  arches 
of  each  vertebra  (10).  To  these  must 
be  added  the  various  epiphyseal  cen- 
tres which  appear  later.  The  carti- 
lage gradually  becomes  ossified,  and 
the  various  component  parts  of  the 
sacrum  fuse  together.  The  alaa  are 
the  first  portions  to  become  united, 
after  which  the  vertebral  bodies  gradually  become  welded  together,  the 
fusion  extending  from  below  upward.  According  to  Litzmann.  the  bodies 
of  the  sacral  vertebras  are  not  entirely  united  until  the  seventh  year,  and 
complete  ossification  of  the  sacrum  is  not  effected  until  the  jwcnty-Mft|i 
year.  Fig.  22  represents  the  disarticulated  pelvis  of  a  child  three  years  old. 
and  clearly  shows  the  extent  to  which  ossification  has  progressed  at  that  age. 

The  pelvis  of  the  new-born  child  differs  from 
that  of  the  adult  not  only  in  being  made  up  of  a 
large  number  of  bones  which  are  united  by  cartilage, 
but  more  particularly  in  its  characteristic  shape. 
This  is  clearly  seen  upon  comparing  Figs.  2-i  and 
25,  which  represent  vertical  mesial  sections  through 
the  pelvis  of  a  new-born  child  and  an  adult  woman. 
In  the  former  the  vertebral  column  is  almost  ver- 
tical, and  its  lumbar  curvature  practically  absent. 
The  promontory  is  very  slightly  marked,  and  is  situ- 
ated at  a  much  higher  level  than  m  the  adult.  The 
sacrum  is  almost  straight  from  above  downward,  but 
presents  a  more  marked  lateral  concavity  man  in  the 
adult.  Its  alse  are  only  slightly  developed,  and  as  a 
consequence  the  pelvis  is  relatively  narrower.  The 
iliac  fossa?  are  almost  vertical,  and  the  horizontal 
rami  of  the  pubis  are  far  shorter  than  in  the 
adult.  The  pubic  arch  is  much  more  angular,  while  the  pelvic  inclina- 
tion is  decidedly  greater.  The  superior  strait  is  narrower  and  more 
angular  in  shape,  the  relation  between  the  conjugata  vera  and  the  trans- 
verse diameter  being  100  to  105,  instead  of  100  to  122.5,  as  in  the  nor- 
mal adult  pelvis.  The  cavity  of  the  pelvis  is  relatively  much  smaller, 
and  is  distinctly  funnel-shaped.  The  antero-posterior  and  transverse 
diameters   of  the   pelvic   outlet,   when   expressed  in  terms   of  the   con- 


Fig.  23. — Sagittal  Section 
through  Pelvis  of  Five- 
year-old  Girl.     X  i- 


18 


OBSTETRICS 


jugata  vera,  are  respectively  93  and  73,  instead  of  104.5  and  100  as  in  the 
adult. 

As  we  have  already  indicated,  sexual  differences  make  their  appearance 
at  a  very  early  period.  Fehling  showed  that  they  could  be  detected  as 
early  as  the  fourth  month,  when  he  found  that  the  first  sacral  vertebra 
was  wedge-shaped  in  the  female,  instead  of  cuboidal  as  in  the  male.  His 
results  have  since  been  confirmed  by  a  number  of  observers,  among  whom 
Balandin,  Jiirgens,  and  Arthur  Thompson  may  be  mentioned;  my  own 
work  also  corroborates  their  statements. 

The  pelvis  of  the  female  foetus  or  new-born  child  presents  the  follow- 
ing characteristics  as  compared  with  that  of  the  male:  The  pelvic  canal 


Fig.  24. — Sagittal  Section  through  Body 
or  Newly  Born  Child. 


Fig.  25. — Sagittal  Section  through  Adult 
Woman  (Kelly),  reduced  to  the  Same 
Size  as  Fig.  24  for  Comparison. 


is  less  funnel-shaped,  the  pubic  arch  is  wider,  the  sacro-sciatic  notches 
are  larger,  and  the  lumbar  region  of  the  spinal  column  is  more  markedly 
curved. 

Transformation  of  Foetal  into  Adult  Pelvis. — The  mechanism  by  which 
the  pelvis  of  the  foetus  is  converted  into  the  adult  form  is  of  interest,  not 
only  from  a  scientific  but  also  from  a  practical  point  of  view,  as  it  affords 
important  information  concerning  the  mode  of  production  of  certain  va- 
rieties of  deformed  pelves. 

The  earliest  investigations  upon  this  subject  were  made  by  De  Fr em- 
ery and  Denman,  who  were  followed  by  Litzmann,  Duncan,  Fehling, 
Schroeder,  Veit,  Von  Meyer,  and  others.  At  present  it  is  generally  be- 
lieved that  in  the  evolution  of  the  form  of  the  pelvis  two  sets  of  factors — 


»  THE   PELVIS  19 

developmental  and  inherent  tendencies,  and  mechanical  Influences — are 
concerned  Tnat  the  process  is  qoI  entirely  the  result  ot  the  action  of  me- 
chanical forces  is  manifested  by  the  existence  of  sexual  and  racial  differ- 
ences in  the  adult  pelvis,  bul  especially  by  the  presence  of  the  former  in 
the  foetal  pelvis,  long  before  it  has  been  subjected  to  the  usual  mechanical 

influences.     Moreover,   the  mechanical    influences  which   c e   into   play 

after  birth  arc  identical   in   both  sexes,  but   despite  this  fad    the  sexualj 
differences  become  still  more  accentuated  as  puberty  is  approached.  ' 

The  part  played  by  developmental  and  hereditary  influences  was  clearly 
demonstrated  by  Litzmann,  who  showed  thai  the  female  sacrum  was  char- 
acterized by  a  marked  increase  in  width  as  compared  with '  that  of  the 
male.  At  birth,  in  both  st'xcs,  the  body  of  the  first  sacral  vertebra  is  twice 
as  broad  as  the  al;e  (100  to  50),  but  in  the  adult  the  relation  becomes 
100  to  ^<i  in  the  female,  and  LOO  to  56  in  the  male,  indicating  a  much 
more  rapid  growth  of  the  alae  in  the  former. 

The  effect  exerted  by  mechanical  influences  has  been  particularly 
studied  by  Duncan,  Meyer,  Veit,  and  Schroeder,  while  Kehrer  has  insisted 
upon  the  part  played  by  muscular  action.  According  to  Schroeder,  three 
mechanical  forces  take  part  in  bringing  about  the  final  shape  of  the  pel- 
vis— namely,  the  body  weight,  the  upward  and  inward  pressure  exerted 
by  the  heads  of  the  femora,  and  the  cohesive  force  exerted  at  the  sym- 
physis pubis. 

So  long  as  the  child  remains  constantly  in  the  recumbent  position  these 
forces  are  in  abeyance,  but  as  soon  as  it  sits  up  or  walks,  the  body  weight 
is  transmitted  through  the  vertebral  column  to  the  sacrum,  and,  as  the 
centre  of  gravity  is  anterior  to  its  promontory,  the  force  transmitted  is 
resolved  into  two  components,  one  of  which  is  directed  downward  and  the 
oilier  forward.  Accordingly,  the  two  together  tend  to  force  the  promontory 
of  the  sacrum  downward  and  forward,  a  process  which  can  only  be  accom- 
plished by  the  sacrum  rotating  slightly  about  its  transverse  axis  so  that 
its  tips  would  become  directed  upward  and  backward.  The  displacement  of 
the  latter,  however,  is  limited,  as  it  is  resisted  by  the  strong  sacro-sciatic 
ligaments  which  permit  of  only  slight  extension,  witn  the  result  that  the 
partly  cartilaginous  sacrum  becomes  bent  upon  itself  just  in  front  of  its 
axis — i.  e.,  about  the  middle  of  its  third  vertebra — so  that  its  anterior  sur- 
face becomes  markedly  concave  from  above  downward,  instead  of  flat  as 
it  was  previously.  At  the  same  time  the  body  weight  forces  the  bodies 
of  the  sacral  vertebra  forward,  so  that  they  project  slightly  beyond  the 
alas  and  thus  tend  to  diminish  the  lateral  cavity  of  the  sacrum. 

As  the  anterior  surface  of  the  sacrum  is  wider  than  its  posterior,  the 
bone  tends  to  sink  down  into  the  pelvic  cavity  under  the  influence  of  the 
body  weight,  and  would  prolapse  completely  into  it  were  it  not  held  in 
place  by  the  strong  posterior  ilio-sacral  ligaments  which  suspend  it,  so  to 
speak,  from  the  posterior  superior  spines  of  the  ilium.  As  the  sacrum  is 
pushed  downward  into  the  pelvic  cavity  it  exerts  marked  tension  upon 
the  ilio-sacral  ligaments,  which  in^turn  drag  ihe  posterior  superior  spines 
inward  towards  the  middle  line,  and  consequently  tend  to  rotate  the  an- 
terior  portions  of  the  innominate  bones  outward.    Excessive  outward  rota- 


20 


OBSTETRICS 


tion  is  prevented,  however,  by  the  cohesive  force  exerted  at  the  symphysis, 
but  particularly  by  the  upward  and  inward  pressure  exerted  by  the  heads 
of  the" femora.  Practically,  then,  the  iliac  bone  becomes  converted  into 
a  two-armed  lever,  with  the  articular  surface  of  the  sacrum  as  a  fulcrum; 
as  a  consequence  it  bends  at  its  point  of  least  resistance,  which  is  just 
anterior  to  the  articulation,  and  thus  gives  the  pelvis  a  greater  transverse 
and  a  lesser  antero-posterior  diameter  (Figs,  26,  27).  At  the  same  time  it 
must  be  remembered  that  a  considerable  part  of  the  transverse  widening 


Fig.  26. 


Figs.  26,  27. — Diagrammatic  Kepresentations  of  Sections  through  the  Infantile  and 
Adult  Pelves  (Scbroecler). 


is  more  apparent  than  real,  and  is  due  to  the  relative  shortening  of  the 
conjugata  vera  by  the  downward  and  forward  displacement  of  the  promon- 
tory of  the  sacrum. 

It  is  apparent  that  the  forces  just  mentioned  must  act  in  identically 
the  same  manner  in  the  two  sexes,  so  that  while  they  may  serve  to  explain 
many  points  in  the  transformation  of  the  foetal  into  the  adult  pelvis,  they 
fail  to  give  a  satisfactory  explanation  of  its  sexual  differences,  and  we 
are  therefore  compelled  to  agree  with  Fehling,  Freund,  Joessel,  and  Breus 
and  Kolisko  that  the  latter  must  owe  their  origin  to  certain  congenital 
tendencies  concerning  whose  nature  we  are  as  yet  absolutely  ignorant. 

The  effect  of  the  mechanical  factors  is  particularly  emphasized  in  cer- 
tain abnormal  types,  more  especially  in  the  production  of  certain  varieties 
of  contracted  pelves,  and  has  been  exhaustively  studied  by  Von  Meyer  and 
Schroeder.  In  rare  instances,  as  in  a  case  recorded  by  Gurlt,  none  of  the 
mechanical  forces  came  into  play,  and  we  then  have  an  opportunity  of 
studying  the  development  of  the  pelvis  in  their  absence.  In  Gurlt's  case 
of  a  thirty-one-year-old  hydrocephalic  woman,  who  had  been  bedridden 
since  infancy  and  had  never  sat  or  walked,  the  autopsy  showed  that  the 
pelvis  had  retained  its  fcetal  characteristics. 

The  cohesive  force  exerted  at  the  symphysis  pubis  cannot  act  by  itself, 
as  it  is  manifested  only  when  the  force  exerted  by  the  body  weight  causes 
a  tendency  towards  gaping  of  the  pubic  bones.  Likewise  the  effect  of  the 
upward  and  inward  force  exerted  by  the  femora  cannot  be  observed  by 


THE    PELVIS  21 

itself,  as  this  force  comes  into  play  only  when  it  has  to  read  against  thai 
resulting  from  the  body  weight.    Thus  Ear  the  action  of  the  body  weight 

alone  has  never  been  observed,  though  theoretically  it  tnighi  be  noted  in  an 
individual  presenting  a  split  pelvis  (congenital  lack  of  union  at  the  sym- 
physis pubis)  who  had  never  walked.  Its  action,  however,  lias  been  studied 
experimentally  by  Freund,  who  suspended  a  cadaver  by  the  iliac  crests 
after  cutting  through  the  symphysis,  and  found  that  the  innominate  bones 
gaped  widely. 

The  effect  of  the  combined  action  of  the  body  weigh!  and  the  force 
exerted  by  the  femora  has  been  studied  by  Litzmann  in  cases  of  congeni- 
tal absence  of  the  symphysis  pubis.  In  such  pelves  there  is  a  marked 
transverse  widening  of  the  posterior  portion,  while  the  force  exerted  by  the 
femora  causes  the  anterior  portions  of  the  innominate  bones  to  become 
almost  parallel. 

The  action  of  the  body  weight  and  the  cohesive  force  exerted  at  the 
symphysis,  without  the  upward  and  inward  pressure  exerted  by  the  femora. 
can  be  studied  in  individuals  whose  lower  extremities  are  absent,  and  occa- 
sionally in  cases  of  congenital  dislocation  of  the  hips.  Hoist  has  described 
a  case  in  which  the  lower  extremities  were  congenitally  absent,  the  pelvis 
being  characterized  by  a  marked  increase  in  width  and  a  marked  decrease  in 
its  antero-posterior  diameter.  Owing  to  the  excessive  pressure  exerted  upon 
the  tubera  ischii  in  the  absence  of  the  counteracting  force  exerted  by  the 
femora,  the  innominate  bones  were  rotated  in  such  a  manner  as  to  turn 
their  crests  inward  and  the  tubera  ischii  outward,  thus  producing  a  marked 
transverse  widening  of  the  inferior  strait.  More  or  less  similar  changes 
may  be  observed  in  the  cases  of  congenital  dislocation  of  the  hip,  in  which 
the  patients  have  never  walked. 

The  effect  of  the  various  mechanical  influences  is  particularly  empha- 
sized when  they  are  exerted  upon  pelves  whose  bones  are  softened  by  dis- 
ease, as  in  rhachitis  and  osteomalacia.  But  the  consideration  of  the 
changes  so  produced  will  be5  deferred  until  the  study  of  the  deformed 
pelves  is  taken  up. 

LITERATURE 

Araxtius.     Anatomicae  observations.     Cap.  XXXIX,  Venetiis,  1857. 

Balaxdix.     Klinisehe  Vortrage,  Heft  1,  St.  Petersburg,  1883. 

Bar.     Influence  de  la  position  de  la  femme  sur  la  forme,  l'inclinaison  et  les  dimensions 

du  bassin.     L'Obstetrique,  iv,  529-542.  1899. 
Breisky.     Zeitsehrift  der  Gesell.  der  Aerzte,  Wien,  i,  21,  1865. 
Breus  and  Kolisko.    Die  pathologisehe  Beckenformen.  Bd.  I.  Theil  I.  Leipzig  u.  Wien; 

1899. 
Columbus.     De  re  anatomica,  Libri  XV.  Venetiis.  1559. 
De  Fremery.    De  mutationibus  figura?  pelvis.     D.  I..  Lugd.  Batav.,  1793. 
Denman.     An  Introduction  to  the  Practice  of  Midwifery.     London,  1787-1795. 
Devexter.     Xeues  Hebammenlicht,  etc.     III.  Aiifl..  Jena,  1728. 
Duncan.     Researches  in  Obstetrics.    Edinburgh.  1868. 
(On  the  Os  Sacrum,  55-82.) 

(On  the  Development  of  the  Female  Pelvis.  95-113.) 
Fehling.     Die  Form  des  Beckens  beim  Fotus  and  Xeugeborenen.     Archiv  f.  Gyn..  x, 

1-SO,  1876. 


22  OBSTETRICS 

Pbeund.      Ueber   das   sogenannte    kyphotische    Becken,   etc.      Gynakologische    Klinik, 

i,  1-113,  1885. 
Gurlt.     Ueber  einige  Missgestaltungen  des  weibliehen  Beckens.     Berlin,  1854. 
Hegar.     Zur  Geburtsmechanik.     (Die  Beckenaxe.)     Archiv  f.  Gyn.,  i,  193-223,  1870. 
Hodge.     The  Principles  and  Practice  of  Obstetrics.     Philadelphia,  1860. 
Holst.     Beschreibung  des  Beckens  u.  der  Geburtstheile  eines  40  Jahre  alten  weibliehen 

Amelus.  Hoist's  Beitrage,  Heft  2,  145-148,  1869. 
Huwe.  Onderwys  der  vrouwen,  etc.  Haarlem,  1735. 
Joessel  and  Waldeyer.     Lehrbuch  der  topographisch-chirurgischen  Anatomic     Bonn, 

1899.     II.  Theil,  Das  Becken. 
Jurgens.     Beitrage  zur  normalen  und  path.  Anatomie  des  menschlichen  Beckens.     Vir- 

chow's  Festschrift,  Berlin,  1891. 
Kehrer.     Beitrage  zur  vergl.  u.  exper.  Geburtshiilfe,  Heft  3, 1869  ;  und  Heft  5, 1875. 
Klein.     Zur  Mechanik  des  Ileosacralgelenkes.     Zeitschr.  f.  Geb.  u.  Gyn.,  xxi,  74-118, 1891. 
Kuttner.     Experimentell-anat.  Untersuchungen  iiber  die  Veranderlichkeit  des  Becken- 

raumes  Gebarender.     Hegar's  Beitrage,  i,  210-229,  1898. 
Levret.     L'art  des  accouchements.     Paris,  1751. 
Litzmann.     Die  Formen  des  Beckens.     Berlin,  1861. 
Das  gespaltene  Becken.     Archiv  f.  Gyn.,  iv,  266-284,  1872. 
Die  Geburt  bei  engem  Becken.     Leipzig,  1884. 
Luschka.     Die  Anatomie  des  menschlichen  Beckens.     Tubingen,  1864. 
Meyer.     Statik  und  Mechanik  des  menschlichen  Knochengeriistes.     Leipzig,  1873. 
Michealis.     Das  enge  Becken.     Leipzig,  1851. 

MiJLLER,  J.  J.     Diss.  sist.  casum  rarissimum  uteri  in  partu  rupti.    Basileae,  1745. 
Naegele.     Das  weibliche  Becken,  etc.     Carlsruhe,  1825. 
Prochownick.     Ueber  Beckenneigung.    Archiv  f.  Gyn.,  xix,  1-95,  1882. 
Roederer.     De  axi  pelvis.     Goettingae,  1751. 

Elementa  artis  obstetriciae.     Goettingae,  1766. 
Schroeder.     Lehrbuch  der  Geburtshiilfe.  XIII.  Aufl.,  1899. 
Smellie.     A  Treatise  on  the  Theory  and  Practice  of  Midwifery.     London,  1752. 
Stein,  D.  J.     Lehre  der  Geburtshiilfe.    Elberfeld,  1825. 
Thompson.    The  Sexual  Differences  of  the  Foetal  Pelvis.    Journal  of  Anat.  and  Physiol., 

xxxiii,  359-381,  1899. 
Topinard.     Des   proportions   generales   du   bassin  chez  l'homme.  etc.     Bull,  de  la  Soc. 

d'Anthropologie,  504-521,  1875. 
Turner.     The  Index  of  the  Pelvic  Brim  as  a  Basis  of  Classification.     Journal  of  Anat. 

and  Physiol.,  xx,  1886. 
Veit.     Die  Entstehung  der  Form  des  Beckens.    Zeitschr.  f.  Geb.  u.  Gyn.,  ix,  347-372, 1883. 
Veit,  J.     Die  Anatomie  des  Beckens.     Stuttgart,  1887. 
Verneau.     Le  bassin  dans  les  sexes  et  dans  les  races.     Paris,  1875. 
Vesalius.     De  humani  corporis  fabrica  libri  septem.     Basilae,  1543. 
Walcher.    Die  Conjugata  eines  engen  Beckens  ist  keine  konstante  Grosse,  etc.    Centralbl. 

f.  Gyn.,  1889,  892,  893. 
Weber.     Die  Lehre  von  Ur-  und  Racenformen  des  Schadels  und  Beckens  des  Menschen. 

Diisseldorf,  1830. 
Wehle.     Die  Walcher'sche   Hangelage   und  ihre  praktische  Verwerthung  bei   geburts- 

hiilflichen  Operationen.     Archiv  f.  Gyn.,  xlv,  323-336,  1894. 
Williams.     The  Frequency  of  Contracted  Pelves,  etc.     Obstetrics,  i,  Nos.  5,  6,  1899. 


CHAPTEE   11 
THE  FEMALE   ORGANS   OF  GENERATION 

For  convenience  in  description  and  on  account  of  their  differences  in 
function,  the  female  organs  of  generation  are  divided  into  two  groups — 
the  external  and  the  internal — the  vagina  being  usually  classed  with  the 
former.  The  external  organs,  together  with  the  vagina,  serve  more  espe- 
cially for  copulation,  while  the  internal  organs  are  directly  concerned  with 
the  development  and  birth  of  the  foetus. 

THE  EXTERNAL  GENERATIVE  ORGANS 

The  term  pudendum  is  occasionally  applied  to  the  external  organs 
of  generation,  although  the  more  common  designation  is  the  vulva.  This 
includes  everything  which  is  visible  externally  from  the  lower  margin  of 
the  pubis  to  the  perinanim — namely,  the  Mons  Veneris,  the  labia  majora 
and  minora,  the  clitoris,  vestibule,  hymen,  urethral  opening,  and  various 
glandular  and  vascular  structures. 

Mons  Veneris. — The  Mons  Veneris  is  the  name  given  to  the  fatty 
cushion  which  rests  upon  the  anterior  surface  of  the  symphysis  pubis. 
Alter  puberty  the  skin  over  it  is  covered  by  a  thicker  or  thinner  growth  of 
crinkly  hair,  which  is  sometimes  described  as  the  "  escutcheon."  Generally 
speaking,  the  distribution  of  the  pubic  hairs  differs  considerably  in  the 
two  sexes.  In  the  female  they  occupy  a  triangular  area  whose  base  cor- 
responds to  the  upper  margin  of  the  symphysis,  while  a  few  hairs  extend 
down  over  the  outer  surface  of  the  labia  majora.  In  the  male,  on  the 
other  hand,  the  escutcheon  is  not  so  circumscribed,  as  the  hairs  composing 
it  extend  triangularly  upward  towards  the  umbilicus  and  downward  over 
the  inner  surface  of  the  thighs.  These  differences  were  described  in 
detail  by  Ploss,  and  at  one  time  it  was  believed  that  they  might  be  of  value 
in  determining  the  sex  in  doubtful  cases.  But  Sehultze  showed  that  such 
variations  were  not  absolutely  characteristic,  and  my  own  experience  has 
convinced  me  that  the  female  escutcheon  not  infrequently  approaches  the 
male  type. 

Vulva. — In  the  restricted  sense,  the  term  vulva  (from  the  Latin  valva, 
or  folding-door),  or  rima  pudendi,  is  applied  only  to  the  structures  lying 
beneath  the  Mons  Veneris.  Its  position  varies  according  to  the  inclination 
of  the  pelvis,  but  it  usually  runs  horizontally  when  the  woman  is  in  the 
erect  position.     It  presents  marked  individual  variations  in  appearance, 

23 


24  OBSTETRICS 

but  its  most  noteworthy  differences  are  dependent  upon  the  age  of  the 
person  and  whether  or  not  she  has  borne  children. 

Labia  Majora. — On  either  side  of  the  vulva  extends  a  rounded  mass  of 
tissue,  the  labium  majus.  The  labia  majora  vary  markedly  in  appearance, 
according  to  the  amount  of  fat  beneath  them.  They  are  less  prominent 
after  childbearing,  and  in  old  age  usually  assume  a  shrivelled  appearance. 
Ordinarily  they  measure  7  to  8  centimetres  in  length,  2  to  3  centimetres 
in  width,  and  1  to  1.5  centimetres  in  thickness.  They  are  somewhat 
lozenge-shaped,  and  become  narrower  at  their  lower  extremities.  In  chil- 
dren and  virginal  adults  they  usually  lie  in  close  apposition  and  completely 
conceal  the  underlying  parts,  whereas  in  multiparous  women  they  often 
gape  widely.     Until  recently  it  was  usually  stated  that  they  were  con- 


~ 

. 

^mmmf 

f 

i 

\ 
\ 

\ 
\ 

/ 

/ 

* 

\ 

fc^,.. 

--  --■-**_ ■■ 

i /    f 

-"-  --^-  >^  : j 

Fig.  28. — External    Genitalia   of   Multipa-  Fig.  29. — External    Genitalia  of   Multipa- 

rous Woman,  Labia  in  Contact.  rous  Woman,  Labia  spread  Apart. 

nected  above  and  below  by  the  anterior  and  posterior  commissures  of 
the  vulva,  but  Luschka  has  shown  that  they  are  directly  continuous 
with  the  Mons  Veneris  above,  and  fade  away  into  the  perinamm  pos- 
teriorly. 

Each  labium  majus  presents  two  surfaces,  an  outer  and  an  inner.  The 
outer  surface  corresponds  in  structure  to  the  adjacent  skin,  and  after  the 
age  of  pubert}^  is  more  or  less  thickly  covered  with  hair.  In  women  who 
have  never  borne  children  the  inner  surface  is  moist  and  resembles  a 
mucous  membrane  in  appearance;  whereas  in  multiparas  it  becomes  more 
skin-like,  but  is  not  covered  with  hair.  It  is  richly  supplied  with  seba- 
ceous glands.  Beneath  the  skin  there  is  a  layer  of  dense  connective  tissue, 
which  is  rich  in  elastic  fibres  and  adipose  tissue,  but  does  not  contain  mus- 


THE   EXTERNAL  GENERATIVE   ORGANS  25 

cular  elements.  Beneath  this  layer,  which  corresponds  to  the  tunica 
dartos  of  the  scrotum,  is  a  tolerably  dense  mass  of  Eat,  to  which  the  labium 
owes  the  greater  part  of  its  size.  This  fatty  tissue  i-  supplied  with  an 
abundanl  plexus  of  veins,  which  may  rupture  as  the  result  of  external  vio- 

lenc •  injury  sustained  during  labour,  and  give  rise  to  an  extravasa 

of  blood  or  haematoma. 

The  labia  majora  art-  analogous  jji  the  M-rotum  in  the  male,  ami  at  their 
upper  ends  receive  the  termination  of  the  round  ligaments.  Exceptionally 
"lie  or  both  of  the  inguinal  canals,  which  in  the  female  are  designated 
as  the  canals  of  .Xurk.  may  remain  patent,  so  that  in  rare  instances  there 
results  ahernial  sac  which  usually  contains  intestine,  but  occasionally 
the  tube  or  ovary,  ami  possibly  even  the  uterus. 

Labia  Minora. — On  spreading  apart  the  labia  majora  two  triangular 
structures  are  seen,  which  meet  together  at  the  uppermosl  portion  of  the 
vulva  and  more  or  less  resemble  a  cockscomb  in  appearance.  These  are 
the  labia  minora  or  ni/m/iJur\  so  called  because  they  were  supposed  to 
direct  the  course  of  the  urine.  They  vary  markedly  in  size  and  shape,  and 
in  nulliparous  women  are  usually  hidden  by  the  labia  majora.  In  multip- 
ara?, on  the  other  hand,  they  project  beyond  them. 

Tbe  labia  minora  consist  of  thin  folds  of  tissue,  which  when  protected 
present  a  moist,  reddish  appearance,  similar  to  that  of  a  mucous  mem- 
brane. They  are,  however,  covered  by  stratified  epithelium,  into  which 
project  numerous  papilla3.  They  have  no  hairs  upon  them, 'but  contain 
many  sebaceous  follicles  and  occasionally  a  few  sweat  glands.  Their  in- 
terior portions  are  made  up  of  connective  tissue,  m  which  are  many 
sels  and  a  few  non-striated  muscular  fibres,  so  that  they  are  classed  among 
the  erectile  structures.  They  are  extremely  sensitive,  and  are  abundantly 
supplied  with  the  several  varieties  of  terminal  nerve-endings,  as  has  been 
shown  by  the  work  of  Krattse,  Carrard,  and  "Webster. 

The  labia  minora  converge  anteriorly,  each  dividing  towards  its  upper 
extremity  into  two  lamella3.  Of  these  the  two  lower  fuse  together  and 
form  the  frenulum  clitoridis,  while  the  upper  ones  make  the  prceputium. 
Posteriorly  they  either  pass  almost  imperceptibly  into  the  labia  majora, 
or  approach  the  middle  line  as  low  ridges,  which  fuse  together  and 
form  the  frenulum  labiorum  or  fourchette  (Luschka,  Cullingworth,  and 
Nagel).. 

According  to  Xagel,  the  labia  minora  are  homologous  with  the  skin 
upon  the  under  surface  of  the  penis.  Xot  infrecpiently  they  become  con- 
siderably hypertrophied,  either  from  unknown  causes  or  as  a  result  of 
masturbation.  Among  the  Hottentots  they  assume  immense  proportions, 
and  project  from  the  vulva  in  the  form  of  an  apron  some  centimetres  long. 
Among  certain  uncivilized  races,  voluminous  labia  minora  are  considered 
to  enhance  the  beauty  of  their  possessors,  and  artificial  means  are  em- 
ployed to  bring  about  an  increase  in  their  size.  According  to  Ploss,  the 
Nubians  and  many  other  races  practise  infibulation  as  part  of  their  re- 
ligious ceremonial.  In  this  operation,  which  is  performed  just  before 
the  age  of  puberty,  the  edges  of  the  labia  are  freshened  with  a  knife, 
and  then  sutured  together  in  such  a  manner  as  to  leave  an  opening  only 


26 


OBSTETRICS 


Vestibular 
bulbs 


large  enough  to  permit  the  escape  of  the  menstrual  flow.  Under  such 
circumstances  a  second  operation  is  necessary  before  marriage  can  be  con- 
summated. 

Clitoris. — The  clitoris  is  situated  at  the  most  anterior  portion  of  the 
vulva,  and  projects  through  the  branched  extremities  of  the  labia  minora 
which  form  its  prepuce  and  frenulum.  It  is  the  analogue  of  the  penis 
in  the  male,  from  which  it  differs  injiot  possessing  a  corpus  spongiosum, 

and  in  not  being  per- 
the  urethra. 


It  consists  of  a  glans,  a 
corpus,  and  two  crura. 
The  crura  are  long,  nar- 
row structures  which 
arise  from  the  inferior 
surface  of  each  ischi^; 
pubic  ramus  and  fuse 
together  in  the  middle 
line,  just  below  the 
pubic  arch,  to  form  the 
body  of  the  clitoris. 
The  clitoris  is  usually 
a  very  rudimentary  or- 
gan and  rarely  exceeds 
2  centimetres  in  length, 
even  when  in  a  state  of 
erection.  It  is  sharply 
bent  on  itself,  owing  to 
traction  exerted  upon 
it  by  the  labia  minora, 
whose  anterior  extrem- 
ities, as  has  already  been  said,  furnish  the  prepuce  and  frenulum.  As  a 
result,  its  free  end  looks  downward  and  inward  towards  the  vaginal  open- 
ing. At  the  end  of  the  body  is  the  glans,  which  rarely  exceeds  a  small  pea 
in  size.  It  is  covered  by  squamous  epithelium,  is  richly  supplied  with 
nerve-endings,  and  is  extremely  sensitive.  The  entire  clitoris  is  very  erect- 
ile, and  its  vessels  are  connected  with  the  vestibular  bulbs  by  means  of  the 
pars  intermedia.  Fig.  30  gives  a  good  idea  of  the  relations  of  the  clitoris, 
its  crura,  and  the  vestibular  bulbs.  We  are  indebted  to  Kobelt  for  most 
of  our  knowledge  concerning  this  organ,  and  since  the  appearance  of  his 
monograph,  in  1844,  the  clitoris  has  been  regarded  as  the  chief  seat  of 
voluptuous  sensation. 

About  the  middle  of  the  last  century  Baker  Brown  proposed  its  am- 
putation as  a  panacea  for  nearly  all  the  ills  to  which  women  are  subject, 
and  for  a  short  time  the  operation  of  cUtoridectomy  enjoyed  a  marked 
vogue,  but  has  since  been  completely  abandoned.  Among  many  of  the 
aboriginal  races  the  same  operation  had  been  performed  from  time  imme- 
morial as  a  religious  rite,  and  was  designated  as  "  girl  circumcision."  Oc- 
casionally the  clitoris  may  become  considerably  hypertrophied,  so  as  to 


Fig.  30.- 


-Pp.epakation  showing  Clitoris  and  its  Vascular 
Supply. 

(Modified  from  Chrobak  and  Eosthorn.) 


THE    EXTERNAL  GENERATIVE   ORGANS  1'T 

markedly  resemble  the  penis,  and  aol  a  EeM  cases  of  so-called  hermaphro- 
ditism are  to  be  explained  by  this  condition. 

Vestibule. — The  vestibule  is  the  almond-shaped  area  which  is  inclosed 
between  the  Labia  minora  and  extends  from  the  clitoris  to  the  Eourchette. 
It  is  the  ivnmani  of  the  uro-genital  sinus  of  the  embryo,  and  is  perforated 
by  four  openings — the  urethra,  the  vaginal  opening,  and  the  ducts  of 
Bartholin's  glands.  Considerable  uncertainty  exists  as  to  its  boundaries, 
for  the  reason  thai  the  French  anatomists  usually  describe  it  as  a  trian- 
gular area,  bounded  above  by  the  labia  minora  and  below  by  the  vaginal 
opening.  The  posterior  portion  of  the  vestibule,  between  the  Eourchette 
and  the  vagina]  opening,  is  called  the  fossa  navieularis.  It  is  rarely  ob- 
served except  in  uulliparous  women,  as  it  usually  becomes  obliterated  after 
childbirth. 

Vestibular  Glands. — In  connection  with  the  vestibule,  certain  glandu- 
lar structures — the  glandulos  vestibularis  majores  and  minnn-s — are  usu- 
ally described.  The  ioriner  are  designated  as  Bartholin's  glands,  or  the 
glands  of  Duverney,  who  first  described  them  in  the  cow.  They  are  two 
small  structures  varying'  from  a  pea  to  a  small  bean  in  size,  and  are 
situated  beneath  the  vestibule,  opposite  the  lateral  margins  of  the  vaginal 
opening.  They  lie  under  the  constrictor  muscle  of  the  vagina,  and  in  a 
few  instances  are  found  to  be  partially  covered  by  the  vestibular  bulbs. 
They  are  compound  racemose_glands;  their  ducts,  from  1.5  to  2  centime!  res 
long,  open  uponthe  sides  oftHesvestibule  just  outside  the  lateral  mar- 
gin of  the  vaginal  orifice.  In  calibre  they  are  usually  small,  and  the  lumen 
will  admit  only  a  bristle.  Under  the  influence  of  sexual  excitement  the 
glands  secrete  a  small  amount  of  yellowish  material.  The  ducts  not  infre- 
quently harbour  gonococci,  which  may  gain  access  to  the  gland  and  cause 
it  to  suppurate,  so  that  the  entire  labium  becomes  markedly  distended  by 
a  collection  of  pus. 

The  glandule  vestibulares  minores  are  a  number  of  small  mucous 
glands  which  open  upon  the  upper  portion  of  the  vestibule.  Their  ori- 
fices' are  occasionally  several  millimetres  in  diameter,  and  in  such  cases 
they  are  designated  as  lacuna?. 

Urethral  Opening. — The  mouth  of  the  urethra,  or  urinary  meatus. 
is  situated  in  the  middle  line  of  the  vestibule.  1  to  1.5  centimetre  below 
the  pubic  arch  and  a  short  distance  above  the  vaginal  opening.  It  usually 
presents  a  puckered  appearance,  and  its  orifice  appears  as  a  vertical  slit, 
which  on  distention  is  4  or  5  millimetres  in  diameter.  The  para-uirllinil 
ducts  open  upon  the  vestibule  on  either  side  of  the  urethra,  and  occasionally 
upon  its  posterior  wall,  just  inside  its  mouth.  They  are  of  small  calibre,  ', 
millimetre  in  diameter,  of  varying  length,  and  in  this  country  are  generally 
known  as  Skene's  ducts.  They  were,  however,  described  by  Malpighi  in  the 
last  century.  Considerable  discussion  has  arisen  as  to  their  origin,  and 
certain  observers,  notably  Kocks,  believe  that  they  represent  the  lower 
extremities  of  the  Wolffian  ducts.  Most  authorities,  however,  do  not  share 
this  view,  and  believe  that  they  are  simply  exaggerated  lacuna3. 

Vestibular  Bulbs. — Lying  beneath  the  mucous  membrane  of  the  vesti- 
bule, on  either  side,  are  the  vestibular  bulbs.     These  are  almond-shaped, 


28  OBSTETRICS 

erectile  bodies,  3  to  4  centimetres  long,  1  to  2  centimetres  wide,  and  0.5 
to  1  centimetre  thick.  They  lie  in  close  apposition  to  the  ischio-pubic 
rami,  and  are  partially  covered  by  the  ischio-cavernosus  and  constrictor 
Yao-rme  muscles.  Their  lower  ends  usually  terminate  about  the  middle  of 
the  vaginal  opening,  while  their  anterior  extremities  extend  upward  to- 
wards the  clitoris,  where  they  are  united  by  the  pars  intermedia  through 
which  the  blood  from  them  reaches  that  organ.  They  were  first  described 
by  Kobelt,  and  their  vascular  connections  have  been  exhaustively  studied 
by  Gussenbauer. 

Embryologically  they  correspond  to  the  corpus  spongiosum  of  the 
penis.  During  parturition  they  are  usually  pushed  up  beneath  the  pubic 
arch,  but  as  their  posterior  ends  partially  encircle  the  vagina,  they  are 
liable  to  be  injured  to  a  greater  or  less  extent,  and  their  rupture  may  give 
rise  to  a  haunatoma  of  the  vulva  or  to  profuse  external  haemorrhage  if 
the  tissues  covering  them  are  torn  through. 

Vaginal  Opening'  and  Hymen. — The  vaginal  opening  occupies  the  lower 
portion  of  the  vestibule  and  varies  markedly  in  size  and  shape  in  different 
individuals.  In  virgins  it  is  entirely  hidden  from  view  by  the  overlapping 
labia  minora,  and,  when  exposed  by  folding  them  back,  appears  almost 
completely  closed  by  a  membranous  structure  known  as  the  hymen. 

The  hymen  presents  marked  differences  in  shape  and  consistence.  In 
the  new-born  child  it  is  a  redundant  structure  which  projects  considerably 
beyond  the  surrounding  parts,  while  in  adult  virgins  it  is  a  membrane  of 
varying  thickness  which  closes  the  vaginal  opening  more  or  less  com- 
pletely, and  presents  an  aperture  which  varies  in  size  from  a  pin's  point 
to  a  calibre  which  will  readily  admit  the  tip  of  one  or  even  two  fingers. 
The  hymeneal  opening  is  usually  crescentic  or  circular  in  shape — hymen 
semilunaris  or  annularis.  In  rare  instances  it  may  assume  other  forms, 
which  have  been  studied  more  particularly  by  Dohrn  and  Budin;  the  most 
important  varieties  being  the  cribriform,  septate,  and  denticulate  or  fim- 
briated hymen.  In  very  rare  instances  the  membrane  may  be  imperforate 
and  lead  to  the  retention  of  the  menstrual  discharges.  Dohrn  devoted  par- 
ticular attention  to  the  fimbriated  variety,  and  stated  that  it  might  be 
mistaken  by  an  inexperienced  observer  for  a  ruptured  hymen,  so  that  this 
type  possesses  some  little  medico-legal  interest. 

According  to  the  embryologieal  researches  of  ISTagel,  the  hymen  repre- 
sents the  lowest  portion^of  the  vagina,  which  in  early  embryos  is  composed 
of  a  solid  mass  of  epithelial  cells.  After  proliferating  rapidly  for  a  time 
the  most  centrally  situated  cells  begin  to  degenerate  and  a  lumen  is  pro- 
duced, except  at  the  lower  extremity  of  the  mass,  where  the  cells  persist 
and  give  rise  to  the  hymen.  The  hymen,  therefore,  is  a  fold  of  tissue 
presenting  a  structure  similar  to  that  of  the  vagina — namely,  a  connective- 
tissue  core  which  is  covered  on  either  side  by  a  layer  of  stratified  epithe- 
lium,  in  which  are  numerous  papilla?  containing  vessels  and  nerve-endings. 

The  hymen  may  vary  markedly  in  consistence  in  different  individuals. 
According  to  Dohrn,  many  types  are  observed — from  a  delicate  structure 
resembling  a  spider's  web  to  a  fleshy,  ligamentous,  or  even  cartilaginous 
membrane,  which  in  rare  instances  has  even  been  described  as  "  bony/' 


PLATE    II. 


» 


Infantile. 


Annular. 


Semilunar. 


Vertical.  Normal  injury  at  coitus.  Caruneulce  myrtiformes. 

SHOWING  SEVERAL  VARIETIES   OF  HYMEN. 


TIIK    EXTERNAL   (MONEKATIYE    OKCSAXS 


29 


In   the  matter  of  elasticity  again,  wide   variations  are   me1    with,  some 
hymens  being  so  delicate  thai  they  rupture  upon  the  slightest  touch,  while 

others,  though  capahle  of  considerable  dis- 
tention, siill  remain  unbroken,  and  later  may 
even  regain  their  original  appearance. 

As  a  general  rule  the  hymen  ruptures  at 

the  first  coitus,  tearing  at  several  points, 
usually  in  its  posterior  portion.  The  edges 
of  the  tears  soon  cicatrize,  and  the  hymen 
becomes  permanently  divided  into  two  or 
three  portions,  which  are  separated  by  nar- 
row slits  extending  down  to  its  base.  (Plate 
II.)  The  extent  to  which  rupture  occurs 
varies  with  the  structure  of  the  hymen  and 
the  degree  to  which  it  is  distended,  being 
most  marked  when  it  is  delicately  formed. 
Although  it  is  generally  believed  by  the 
laity  that  its  rupture  is  associated  with  hem- 
orrhage, this  is  by  no  means  always  the  case, 
though  in  rare  instances  such  a  profuse  loss  I   fig.  31.  —  Longitudinal 

of   blood    may    OCCUr    as   to    lead   to    profound  I        showing    Transition   from   the 

anasmia  and  even  death.  This  idea  is  prob- 
ably based  upon  the  biblical  statement  that 
loss  of  virginity  is  always  associated  with 
loss  of  blood.  Nor  is  it  unreasonable  to 
suppose  that  considerable  bleeding  usually  oc- 

cured  among  the  Hebrews  of  the  biblical  period,  inasmuch  as  the  girls 
married  very  young,  and  not  infrequently  before  the  age  of  puberty,  so 

that  marked  disproportion 
must  often  have  existed  be- 
tween the  size  of  the  male  and 
female  organs.  On  the  other 
hand,  it  must  be  remembered 
that  where  Western  civiliza- 
tion prevails  full  sexual  de- 
velopment has  usually  been 
attained  before  marriage. 

In  rare  instances  the 
membrane  may  be  very  resist- 
ant and  surgical  interfer- 
ence be  required  before  coitus 
can  be  accomplished.  Ober- 
taufer,  in  1802,  reported  a 
case  in  which  the  hymen  was 
so  tough  that  it  creaked  under 
the  knife.  Occasionally,  in- 
stead of  giving  way  in  the  middle,  it  may  be  torn  loose  from  its  base  in  the 
attempt  at  coitus,  while  in  other  cases  the  penis  may  dilate  the  urethral 


'-'-'or;  e    "j 


Cylindrical  Epithelium  of  the 
Uterus  to  the  Cuboidal  Epi- 
thelium of  the  Vagina. 

From  11  10-centhnetre  embryo  1  Na- 
gel).     U.,  uterus  ;    V.,  vagina. 


Fig.  32. — Sagittal  Section  through  the  Lower 
Portion  of  the  Vagina  of  a  14-Centimetre 
Embryo  (Xagel). 

U.,  urethra  ;  H.,  hymen  ;   Vag.,  vagina. 


so 


OBSTETRICS 


canal  instead  of  entering  the  vagina.  Neugebauer  has  lately  collected  an 
interesting  series  of  injuries  occurring  during  coitus,  many  of  which  were 
due  to  the  presence  of  a  very  resistant  hymen. 

The  changes  in  the  hymen  folloAving  coitus  are  often  of  medico-legal 
interest,  as  the  physician  is  occasionally  called  upon  to  testify  as  to  the 
virginity  of  an  individual.  Unfortunately,  however,  it  is  not  always  pos- 
sible to  arrive  at  a  decisive  conclusion  as  to  this  point.  In  occasional 
instances  the  hymen  may  be  destroyed  in  early  childhood,  either  as  the 
result  of  masturbation  or  as  a  consequence  of  attempting  to  get  rid  of 
seat-worms.     Among  certain  Eastern  races,  again,  it  is  ruptured  in  early 

childhood  for  purposes  of  clean- 
liness. On  the  other  hand,  the 
hymen  may  not  be  torn,  despite 
repeated  coitus  ;  whereas,  in 
other  instances,  the  denticulate 
or  fimbriated  type  may  be  mis- 
taken for  a  hymen  Which  has 
been  ruptured.  Haberda,  the 
Professor  of  Legal  Medicine  in 
Vienna,  lately  stated  that  he  was 
able  to  make  a  positive  diagnosis 
of  loss  of  virginity  in  only  about 
50  per  cent  of  the  medico-legal 
cases  which  he  had  examined  in 
the  last  five  years.  He  believes 
that  in  many  instances  it  is  im- 
possible to  determine  whether 
coitus  has  taken  place  or  not, 
unless  the  individual  is  seen 
immediately  after  the  attempt, 
before  the  torn  surfaces  have  had 
an  opportunity  to  unite.  Achen- 
bach,  in  a  recent  dissertation, 
collected  25  instances  of  preg- 
nancy occurring  in  women  with  unruptured  hymens;  while  Kanony  has 
collected  43  similar  reports  from  the  literature.  Some  years  ago  I  saw  a 
case  in  which  conception  had  occurred  through  an  elastic  hymen  which  pre- 
sented only  a  pin-point  opening. 

The.  changes  produced  by  childbirth  are  much  more  marked  than 
those  following  coitus,  and,  as  a  rule,  are  readily  recognised.  As  the 
result  of  the  distention  incident  to  the  birth  of  the  child,  the  hymen 
undergoes  pressure_nj?cjmLs-in  various  places,  and  after  the  puerperium 
the  remnants  are~represented  by  a  number  of  cicatrized  nodules  of  varying 
size — the  carunculce  mvrtiformes  (Plate  II).  Their  significance  was  first 
emphasized  by  Schroeder.  Practically  speaking,  they  are  infallible  signs 
of  previous  childbearing,  as  they  can  be  produced  only  by  marked  disten- 
tion and  long-continued  pressure.  In  rare  instances  the  injuries  resulting 
from  childbirth  are  extremely  slight,  and  very  exceptionally  are  entirely 


Fig.  33. — Almost  Unruptured  Hyilen  after 
Childbirth  (Buclin). 


THE   VAGINA  31 

lacking.  Such  cases  have  beeD  reported  by  Hyerneaux,  Tolberg,  Byrtl, 
and  Budin.  Fig.  33  shows  the  external  organs  of  one  of  Budin's  patients 
who  had  given  birth  to  a  full-term  child. 

LITERATURE 

Achexbach.     25  Faile  Ton  Schwangerschaft  unci  Geburl   bei  undurchbohrtera   Hymen, 

I).  I..  Marburg,  1890. 
Budin.     Etecherches  sur  I'hymen  el  l'orifice  raginale.     Le  Progres  Medical,  aout, 
Description  d'un  cas  dans  lequel  I'accouchement   n'a  determine,  chez  une  primipare, 

que  de  legeres  fissures  de  l'orifice  hymenal.     Femmes  en  couches  et   Nouvean- 

Paris,  1897,  1-4. 
Carbabd.     Beitrag  zur  Anatomie  jand  Pathologie  der  kleinen  Labien.    Zeitschr. 

u.  Gyn..  x.  62-93,  1884. 
Ccllingwobth.     A  Note  on  the  Anatomy  of  the  Hymen  and  on  that  of  thi 

Commissure  of  the  Vulva.     Journal  of  Anat.  and  Physiol.,  x.wii.  April,  1893. 
Dohrx.     Die  Bildungsfehler  des  Hymens.     Zeitschr.  f.  Geb.  u.  Gyn..  xi.  1-10.  1885. 
Gussenbauer.     (Jeber  das  Gefasssystem  der  aiisseren  weiblichen  Genitalien.    Sitzut  _-     - 

richt  der  k.  k.  Akad.  der  Wissenschaften,  Wien.  Ix.  1869. 
Habebda.     Ueber  den  anat.  Beweis  der  erfolgten  Defloration.     Monatsschr.  f.  Geb.  n. 

Gyn..  xi.  69-88,  1000. 
Kanony.     De  la  frequence  des  cas  de  persistance  de  I'hymen  et  de  leur  importance  en 

medicine  legale.     These  de  Montpellier,  1899. 
Kobelt.     Die  inannliche  und  weibliehe  TVollustorgane.     Freiburg.  1^44. 
Ko(  k>.     Ueber  die  Gartner'schen  Gauge  beim  Weibe.     Archiv  f.  Gyn..  xx.  487—492,    3€  - 
Kbause.     Die  Nervenendigung  innerhalb  der  terminalen  Korperchen.     Archiv  f.  mikr. 

Anatomie.  xix.  1881. 
Nagel.    Die  weiblichen  Geschlechtsorgane,  Bardeleben's  Handbuch  der  Anatomie,    - 
Ueber  die  Entwiekelung  des  Uterus  und  der  Vagina  beim   Menschen.     Archiv  f.  mikr. 

Anat..  Bd.  XXXVII. 
Neugebatjer.     Ein  Beitrag  zur  Lehre  von  den  Verletzungen  der  weiblichen  Sexualorgane 

sub   coitu.     Alit  Kasuistik  von  157  Beobachtungen.    Monatsschr.  f.  Geb.  u.  Gyn.. 

ix.  221,  1899. 
Ploss.     Das  Weib  in  der  Natur  und  Volkerkunde.     IV.  Ann..  Bd.  I,  Leipzig,  1895. 
Schroeder.     The  Condition  of  the  Hymen  and  its  Remains  after  Cohabitation.  Child- 
bearing,  etc.     Trans.  Edinburgh  Obst.  Soc.  lv?v. 
Scbxltze.    Zur  forensischen  Diagnose  des  Geschlechts.    Jen.  Zeitschr.  f.  Medizin  und 

Natorwissensch.,  iv.  1868. 
Skexe.     The  Anatomy  and  Pathology  of  Two  Important  Glands  of  the  Female  Urethra. 

Amer.  Jour,  of  Obst..  xiii.  265-270,  1880. 
Webster.     The  Xerve-Endings  in  the   Labia   Minora  and  Clitoris.     Edinburgh  Med. 

Journal.  1891. 

THE    VAGINA 

The  vagina  is  a  museulo-membranoiis  tube  which  extends  from  the 
vulva  to  the  uterus,  and  is  interposed  between  the  bladder  and  the  rectum. 
It  serves  three  important  functions:  it  represents  the  excretory  duct  of  the 
uterus,  through  which  its  secretion  and  the  menstrual  flow  escape;  it  is  the 
female  organ  of  copulation:  and,  finally,  it  forms  part  .of  the  birth  canaljat 
labour?  Its  course  runs  almost  entirely  within  the  pelvic  floor,  and  it  is 
therefore  practically  outside  of  the  pelvic  cavity.  The  vaginal  canal  pre- 
sents a  somewhat  S-shaped  curvature.     The  common  statement  that  its 


32 


OBSTETRICS 


course  corresponds  in  direction  to  that  of  the  pelvic  axis  is  incorrect,  since 
its  lower  third  is  parallel  to  the  plane  of  the  superior  strait,  while  its  upper 
portion  presents  a  concavity  corresponding  to  the  curve  of  the  rectum. 

Anteriorly,  the  vagina  is  in  contact  with  the  bladder  and  urethra,  from 
which  it  is  separated  by  the  vesico-vaginal  septum.  Posteriorly,  between 
its  lower  portion  and  the  rectum,  we  have  the  perinaeum  and  recto-vaginal 
septum;  in  its  median  portion  it  lies  in  close  appositionj^jtli  the_rectum, 
while  its  upper  portion  is  separated  frornit  by  Douglas's  cul-de-sac.  In 
view  of  these  relations,  Schauta,  for  the  purposes  of  description,  has 
divided  its  anterior  wall  into  two  parts — urethral  and  vesical — and  its  pos- 
terior wall  into  three — perineal,  rectal,  and  peritoneal  respectively.  The 
urethral  portion  of  the  vagina  is  firmly  united  to  the  urethra  and  vesico- 
vaginal septum,  from  which  it  can  be  separated  only  with  some  difficulty; 
whereas  the  vesical  portion  is  loosely  attached  to  the  bladder  and  can  be 
readily. detached  from  it. 

The  anterior  and  posterior  walls  of  the  vagina  lie  in  contact,  a  slight 
space  intervening  between  their  lateral  margins.  When  not  distended  the 
canal  presents  an  H -shaped  appearance  on  transverse  section,  as  was  first 
pointed  out  by  Henle.  The  vagina  is  capable  of  marked  distention,  as  is 
manifested  at  childbirth  or  when  one  attempts  to  pack  it  with  gauze. 

The  vagina  and  uterus  meet  at  an  acute  angle, 
with  its  opening  looking  forward.  The 
upper  end  of  the  vagina  ends  as  a  blind  vault 
into  ■  which  the  lower  portion  of  the  cervix 
uteri  projects.  The  vaginal  vault,  or,  as  it 
is  usually  designated,  the  fornix,  for  con- 
venience of  description,  is  subdivided  into  the 
anterior,  posterior,  and  two  lateral  fornices. 
As  the  vagina  is  attached  higher  up  upon  the 
posterior  than  upon  the  anterior  wall  of  the 
cervix,  the  posterior  fornix  is  considerably 
deeper  than  the  anterior. 

The  vagina  presents  considerable  individ- 
ual variations  in  length.  Since  it  is  united 
to  the  uterus  at  an  acute  angle,  its  anterior 
is  always  shorter  than  its  posterior  wall — 6 
to  8  or  7  to  10  centimetres  respectively. 
The  vagina  is  relatively  longer  in  the  new- 
born child  than  in  the  adult,  and  according 
to  Luschka  forms  about  i  of  the  body  length 
in  the  former  as  compared  with  T^  in  the 
latter  (Figs.  21  and  25). 

Projecting  from  the  middle  line  of  both 
the  anterior  and  posterior  walls  is  a  promi- 
osterior  vaginal  columns,  the 
latter  not  infrequently  being  cTivTul?a"into  two  parts  by  a  longitudinal  fur- 
row. In  women  who  have  not  borne  children,  numerous  transverse  ridges 
or  rugce  extend  outward  from  and  almost  at  right  angles  to  the  vaginal 


Fig.  34. — H  shaped  Lumen  of 
Vagina  (Henle,). 


nent  longitudinal  ridge — the  anterior  and 


THE   VAGINA 


33 


columns,  gradually  fading  away  as  they  approach  the  lateral  walls.  They 
give  to  the  surface  a  corrugated  appearance,  which  is  more  marked  in  the 
early  years  of  life,  and  gradually  becomes  obliterated  after  repeated  child- 
birth, so  thai  in  old  multipara?  the  sraginal  walls  are  often  perfectly  smooth. 
The  vaginal  wall  Itself  is  composed  of  three  layers — the  mucous,  the 
muscular,  and  the  connective-tissue  layers.  The  mucosa  Is  covered  by 
numerous  lavers  of  stra  tilled  epithelium,  and  closely  resembles  the  skin  in 


structure;  but,  as  its  surface  is  not  "exposed  to  the  air,  the  homy. 

is  absent.    The  lowest  layer  of  epithelium  is  distinctly  columnar  in.ap- 


§ 


ep. 


tour. 

Fig.  35. — Vaginal  Mucosa.     X  90. 
ep.,  epithelium  ;  p.,  papilla  ;  c.t..  connective  tissue. 

pearance,  while  the  cells  immediately  above  it  are  potygonal  in  shape,  and 
gradually  become  more  and  more  flattened  as  the  free  surface  is  ap- 
proached. Beneath  the  epithelium  is  the  submucosa,  a  thin  layer  of  con- 
nective tissue,  which  is  tolerably  rich  in  blood-vessels.  Offshoots  from  it 
extend  up  into  the  epithelium  and  form  papilla3,  just  as  in  the  skin,  and 
scattered  here  and  there  through  the  submucosa  are  small  lymphoid 
nodules.  The  mucosa  is  very  loosely  attached  to  the  underlying  connect- ' 
ive  tissue,  as  is  manifested  by  the  ease  with  which  it  can  be  peeled  off  at 
operations. 

According  to  Eppinger,  Nagel,  Gebhard,  Pretti,  and  Waldeyer,  the 
vaginal  mucosa  is  absolutely  devoid  of  glands,  nor  has  the  writer,  in  any 
of  the  large  number  of  specimens  examined,  ever  encountered  them.  Hen- 
nig  and  Preuschen,  on  the  other  hand,  affirm  that  they  are  not  infrequently 
present,  but  the  statements  of  these  writers  have  not  been  confirmed.  It 
is  true  that  in  rare  instances  Veit  and  Davidsohn  found  a  few,  but  the 
latter  considered  that  they  merely  represented  aberrant  cervical  glands. 

The  muscular  layer  is  not  very  sharply  marked,  and  is  usually  de- 
scribed as  being  composed  of  two  layers  of  non-striated  muscle — an  outer., 
longitudinal,  and  an  inner,  circular  layer.  At  the  lower  extremity  of  the 
vagllia,  Luschka  described  a  thin  band  of  voluntary  muscle,  the  constrictor 
or  sphincter  raqincp.  This  can  always  be  found  in  perineal  dissections, T>ut 
for  practical  purposes  the  levator  ani  muscle  is  the  real  closer  of  the  vagina. 


34  OBSTETRICS 

Outside  of  the  muscular  layer  is  a  layer  of  connective  tissue  which 
serves  to  connect  the  vagina  with  the  surrounding  parts.  It  is  quite  rich 
in  elastic  fibres,  and  contains  an  abundant  venous  plexus. 

In  the  non-pregnant  condition  the  vagina  is  kept  moist  by  a  small 
amount  of  secretion  from  the  uterus;  but  in  pregnancy  a  well-marked  vag- 
inal secretion  is  present,  which,  according  to  Doderlein  and  most  subse- 
quent observers,  normally  consists  of  a  dry,  thick,  white,  curdlike  ma- 
terial composed  of  cast-off  epithelium  and  many  bacteria,  and  presents  a 
markedly  acid  reaction.  A  great  deal  of  wor3TTias  Deer?  done  upon  the 
bacterial  flora  of  the  vaginal  secretion  in  pregnancy,  and  all  observers 
agree  that  bacillary  forms  predominate,  though  cocci  are  not  infrequently 
seen.  The  consensus  of  opinion  is  that  the  ordinary  pyogenic  organisms 
are  never  present  in  the  vaginal  secretion  of  healthy  pregnant  women 
(Kronig  and  Williams).  The  subject  will  be  considered  in  detail  in  the 
chapter  on  Puerperal  Infection. 

The  vagina  possesses  an  abundant  vascular  supply,  its  upper  third 
being  supplied  by  the  cervico-vaginal  branches  of  the  uterine  arteries,  its 
middle  third  by  the  inferior  vesical  _arteries.  and  its  Tower  third  by*  the 
median  hemorrhoidal  and  internal  pudic  arteries.  Immediately  surround- 
ing~^e~vag7naisan  abundant^  venous  plexus,  the  vessels  from  which 
follow  the  course  of  the  arteries  and  eventually  empty  into  the  hypogastric 
veins. 

The  distribution  of  lymphatics  has  been  very  accurately  studied  by 
Poirier,  who  found  that  the  lymphatics  from  the  lower  third  of  the  vagina 
empty  into  the  inguinal,  lymph  glands,  those  from  its  middle  third  into 
the  hypogastric,  and  those  from  its  Qter  third  into  the  iliac  glands. 

The  vagina  is  formed  by  the  fusion  of  the  terminal  ends  of  the  Miil- 
lerian  ducts,  which,  according  to  Nagel,  reach  the  uro-genital  sinus  in  em- 
bryos 2.5  to  3  centimetres  long.  As  has  already  been  said,  when  consider- 
ing the  development  of  the  hymen,  the  vagina,  is  m-jmnnlly  solid,  and  is 
made  up  of  a  mass  of  polygonal  epithelial  cells,  its  lumen  resulting  from 
their  degeneration,  which  commences  at  about  the  third  month  of  gesta- 
tion.    (See  Fig.  31.) 

LITERATURE 

Davidsohn.     Zur  Kenntniss  der  Scheidendrusen,  etc.     Arehiv  f.  Gyn.,  lxi,  418-483,  1900. 

Doderlein.     Das  Scheidensekret.     Leipzig,  1892. 

Eppinger.     Zeitsehr.  f.  Heilkunde,  Bd.  III. 

Gebhard.     Path.  Anatomie  der  weiblichen  Sexualorgane.     Leipzig,  1899,  494. 

Henle.     Eingeweidelehre  des  Menschen.     Braunschweig,  1873. 

Kronig  und  Menge.     Bakteriologie  des  weiblichen  Genitalkanales.     Leipzig,  1897. 

Luschka.     Die  Anatomie  des  menschlichen  Beckens.     Tubingen,  1861. 

Nagel.     Die  weiblichen    Geschlechtsorgane.     (Bardeleben's   Handbuch   der   Anatomie.) 

Jena,  1896. 
Poirier.     Lymphatiques  des  organes  genitaux  de  la  femrae.     Paris,  1890. 
Pretti.      Beitrag  zur   histologischen  Veranderungen  der  Scheide.     Zeitsehr.  f.  Geb.  u. 

Gyn.,  xxxviii,  250-269,  1898. 
Vox  Preuschen.     Virchow's  Arehiv,  lxx. 

Schauta.     Lehrbuch  der  gesammten  Gynakologie.     Leipzig:  u.  Wien,  1896,  51. 
Veit.     Cysten  der  Scheide.     Handbuch  der  Gyn.,  i,  341,  1897. 


THE   NON-PREGNANT    [JTERUS  35 

W  lldeteb  u m I  Joessel.     Lehrbuch  der  topographisch-chirurg.  Anatomie,  II.  Theil,  819. 

Bonn,  L899. 
Williams,  J.  Whitridge.    The  Bacteria  of  the  Vagina  and  their  Practical  Significance. 

Amer.  Jour,  of  Obst.,  xxxviii,  44!)-4^:;.  L898. 


INTERNAL    GENERATIVE    ORGANS 

The  Non-pregnant  Uterus. — The  uterus  is  a  muscular  "structure,  par- 
tially covered  by  peritonaeum,  and  presents  a  small  cavity  lined  by  mucous 
membrane.  Ii  is  the  organ  of  menstruation,  and  during  pregnancy  serves 
for  the  reception,  retention,  and  nutrition  of  the  ovum,  which  it  expels 
at  tli<'  time  of  labour  by  its  contractions. 

Tin'  uterus  is  situated  in  the  pelvic  cavity  between  the  bladder  and 
rectum,  its  inferior  extremity  projecting  into  the  vagina.  Almost  its 
entire  posterior  wall  is  covered  by  peritonaeum,  the  lower  portion  of  which 


Fig.  SO. — Antekiob  Aspect  of  Utep.us.     X  1. 


Fig.  -37. — Postep.ior  Aspect  of  Uteri's.     X  1. 


forms  the  anterior  boundary  of  Douglas's  culjle-sac;  while  only  the  upper 
portion  of  the  anterior  wall  is  socovefeci,  rts  lower  portion  being  united 
to  the  posterior  wall  of  the  bladder  by  a  tolerably  thick  layer  of  connective 
tissue. 

Roughly  speaking,  the  uterus  resembles  a  flattened  pear  in  appear- 
ance, and  consists  of  two  unequal  parts:  an  upper  triangular  portion — the 
corpus — and  a  lower,  cylindrical,  or  fusiform  portion — the  cervix.  The 
anterior  surface  of  the  corpus  is  almost  flat,  while  its  posterior  surface  is 
markedly  convex.  In  view  of  the  fact  that  the  former,  which  looks  down- 
ward and  forward,  rests  upon  the  bladder,  while  the  latter  is  in  contact 
with  the  intestines,  His  has  suggested  that  the  surfaces  be  described  as 
vesical  and  intestinal,  instead  of  anterior  and  posterior  respectively.  The 
Fallopian  tubes  come  off  from  the  cornua  of  the  uterus — i.  e.,  at  the  junc- 
tion of  the  superior  and  lateral  margins  on  either  side — the  convex  upper 
margin  between  their  points  of  insertion  being  known  as  the  fundus  uteri. 


36 


OBSTETRICS 


The  lateral  margins  extend  from  the  insertion  of  the  Fallopian  tubes  on 
either  side  to  the  pelvic  floor.  They  are  not  covered  by  peritonaeum,  but 
receive  the  attachments  of  the  broad  ligaments. 

The  uterus  presents  marked  variations  in  size  and  shape,  according  to 
the  age  of  the  individual,  and  whether  or  not  she  has  borne  children.  The 
infantile  organ  varies  from  2.5  to  3  centimetres  in 
length;  that  of  adult  virgins  measures  from  5.5  to 
8,  3.5  to  4,  and  2  to  2.5  centimetres  in  its  greatest 
vertical,  transverse,  and  antero-posterior  diameters 
respectively,  as  compared  with  9  to  9.5,  5.5  to  6,  and 
3  to  3.5  centimetres  in  multiparous  women.  Virginal 
and  parous  uteri  also  differ  considerably  in  weight, 
the  former  ranging  from  40  to  50,  and  the  latter 
from  60  to  70  grammes.  The  relation  between  the 
length  of  the  corpus  and  that  of  the  cervix  likewise 
varies  widely.  In  the  young  child  the  former  is  only 
half  as  long  as  the  cervix;  in  young  virgins  the  two 
are  of  ecpial  length,  or  the  corpus  may  be  slightly 
longer.  In  multiparous  women,  on  the  other  hand,  the 
relation  is  reversed,  and  the  cervix  represents  only  a 
little  more  than  i  of  the  total  length  of  the  organ. 

On  sagittal  section  it  is  seen  that  the  great  bulk 
of  the  uterus  is  made  up  of  muscular  tissue,  and  that 
the  anterior  and  posterior  walls  of  its  body  lie  almost 
in  contact,  the  cavity  between  them  appearing  as  a 
mere  slit,  while  that  of  the  cervix  is  fusiform  in 
shape  with  a  small  opening  above  and  below — the  in- 
ternal and  the  external  os. 
On  frontal  section  the  cavity  of  the  body  of  the  uterus  presents  a 
triangular  appearance,  while  that  of  the  cervix  retains  its  fusiform  shape. 
After  childbearing,  the  triangular  appearance  becomes  less  marked,  and 
its  margins  become  concave  instead  of  convex,  as  in  the  vaginal  condition. 

Cervix  Uteri. — The  cervix  is  the  portion 
of  the  uterus  which  lies  below  the  internal 
os.  Anteriorly  its  upper  boundary  is  indi- 
cated by  the  point  at  which  the  peritonaeum 
is  reflected  from  the  uterus  on  to  the 
bladder. 

It  is  divided,  by  the  attachment  of  the 
vagina,  into  two  parts:  the  supravaginal 
and  infravaginal  portions  of  the  cervix. 
The  former  is  covered  on  its  posterior  sur- 
face by  peritonaeum,  while  its  lateral  and 
anterior  surfaces  are  in  contact  with  con- 
nective tissue  of  the  broad  ligaments  and 
bladder. 

The  infravaginal  portion  of  the  cervix,  which  is  usually  designated  as 
the  portio  vaginalis,  projects  into  the  vaginal  fornix,  and  at  its  tip  presents 


Fig.  38. — Lateral  Aspect 
of  Uterus,  showing 
Supravaginal  and  In- 
fravaginal Portions 
of  Cervix  and  Ar- 
rangement of  Perito- 
neal Covering.     X 1. 


Fig.    39. — Showing    Junction  of  Va- 
gina and  Cervix  (Skene). 


the  x<l\-1'i;i-;<;xa.\t  itkkis 


37 


a  small  transverse  opening,  the  external  os,  bounded  in  front  and  behind  by 
th«'  so-called  anterior  and  posterior  lips  of  the  cervix.  Owing  to  the  fad 
thai  the  posterior  fornix  is  deeper  than  the  ain.M-i.u-,  the  posterior  lip 
appears  Longer  than  the  anterior. 

The  external  os  may  vary  greatly  in  appearance.  In  the  virgin  it  is  a 
small,  oval  opening  resembling  a  tench's  mouth,  whence  the  nam.',  os  tincce. 
On  vagina]  examination  it  gives  a  sensation  similar  to  that  obtimSoTTJn 
feeling  the  cartilage  at 
the  end  of  one's  nose. 
After  childbirth  the  ori- 
fice becomes  converted 
into  a  transverse  slit,  and 
when  tit.'  cervix  has  been 
markedly  torn  during  la- 
bour, it  may  present  an 
irregular  nodular  or  sti 


Fig.  40. — Uteris  a.vd  Ap 


es  of  Young  Child.     X  §• 


— 


\ 


Fig.  41. — Uterus   and  Appendages   of   F<>urteex-year-old 
Girl.     X  s- 


late  appearance.  These 
changes  are  very  charac- 
teristic, and  enable  one 
to  assert  with  tolerable 
accuracy  whether  a  wom- 
an has  borne  children  or 
not  (Figs.  43  and  44). 

The  cervix  is  com- 
posed of  connective  tis- 
sue in  which  are  many 
nonstriated  muscle  fibres 
and  a  certain  amount  of 
elastic  tissue,  a  large  part 
of  its  distensibility  being 
due  to  the  presence  of  the 
latter.  The  cervical  ca- 
nal, as  has  already  been 
said,  is  fusiform  in  shape, 
and  presents  a  longitudi- 
nal ridge  upon  its  anteri- 
or and  posterior  surfaces, 
from  which  numerous 
others  ran  off  trans- 
versely, giving  the  mem- 
brane a  corrugated  appearance — the  arbor  vita?  uterina  or  plica;  pal  ma  fee. 

In  the  adult  the  arbor  vita?  is  limited  to  the  cervical  canal:  but  in 
childhood  it  extends  throughout  the  entire  cavity  of  the  uterus,  from  which 
it  begins  to  disappear  as  puberty  is  approached.  In  time,  after  repeated 
childbirths,  it  gradually  becomes  obliterated,  even  in  the  cervical  canal, 
whose  walls  become  almost  smooth  (see  Figs.  40  to  42). 

The  mucosa  of  the  cervical  canal,  embryologically  speaking,  is  a  direct 
continuation  of  the  lining  of  the  uterine  cavity,  but  has  become  differenti- 


Fig.  42.- 


-Utervs  and  Appendages  of  Twenty-year-old 
Multipara.     X  §. 


38 


OBSTETRICS 


Fig.  43. — Virginal  Exter- 
nal Os. 


Fig.  44. — Parous  Exter- 
nal Os. 


ated  from  it  and  possesses  a  characteristic  appearance,  so  that  sections 
through  the  canal  present  a  honeycomb-like  structure  (Fig.  45).  The  nm^ 
cosa  is  composedofa  single  layer  of  very  high  and  narrow  columnar  epithe- 
liTniir  w  Men  rests  upon  a  turn  basement  membrane.  The  oyal  nuclei  are 
situated  near  the  base  of  the  columnar  cells,  the  upper  portions  of  which 

present  a  clear,  more  or 
less  transparent  appear- 
ance due  to  the  presence 
of  mucus.  It  is  usually 
stated  that  these  cells 
are  abundantly  supplied 
with  cilia. 

The  cervical  glands 
extend  down  from  the 
surface  of  the  mucosa 
into  the  stroma.  They 
are  of  the  branching,  racemose  variety,  and  are  merely  reduplications  of  the 
surface  epithelium,  being  lined  by  epithelium  of  the  same  character. 
Friedlancler  was  the  first  to  demonstrate  that  it  was  made  up  of  true 
"  beaker  "  or  mucous  cells,  which  furnish  the  thick,  tenacious  secretion  of 
the  cervical  canal.  There  is  no  submucosa  in  the  cervix,  the  mucosa  resting 
directly  upon  the  underlying  tissue. 

The  mucosa  of  the  vaginal  portion  of  the_  cervix  is  directly  continuous 
with  that  of  the  vagina,  anci7"Iik*e'"rt,  consists  ofjiilTnT  layers^of_  stratified 
epithelium.  Xormally,  there  are  no  glands  Beneath  it,  but  occasionally 
those  from  the  cervical  canal  may  extend  down  almost  to  its  surface, 
and  if  their  ducts  are  occluded,  may  become  converted  into  retention  cysts, 
which  shimmer  through  it  and  appear  as  rounded  protuberances  the  size 

of  small  peas.    These  .      

are  the  so-called  Xa- 
bothian  follicles  or 
(yffitffijTfflabofhi. 

"  XofhiaTty,      the  ?.  ^  "-  '-        V-         ,       & 

stratified    epithelium  ^jl*,  ■■  -   -;•■  ,/..'.  '- "      >- 

of  the  vaginal  por- 
tion and  the  cylin- 
drical epithelium  of 
the  cervical  canal 
meet  at  the  external 
os.    This,  however,  is      L 

the  case  only  in  early  Fig.  45.— Cross-section  through  Cervical  Canal X  6. 

life,  as  in  older  per- 
sons the  stratified  epithelium  gradually  extends  up  the  cervical  canal  until 
its  lower  third,  and  occasionally  its  lower  half,  is  covered  by  it  (Friedlander). 
This  change  is  more  especially  marked  in  multiparous  women,  in  whom  the 
lips  of  the  cervix  are  not  infrequently  markedly  everted;  and  occasionally  in 
cases  of  this  character,  almost  the  entire  cervical  canal  may  be  lined  by 
stratified  epithelium. 


j 

--.  V.V.. 


THE   NON-PREGNANT   QTERUS 


::■.» 


In  rare  instances  the  junction  of  the  two  varieties  of  epithelium  may 
be  upon  the  vaginal  portion,  outside  the  external  os.  Tin-  condition  was 
firsl  described  by  Fischel,  who  designated  it  as  congenital  ectropion,  and 
stated  thai  hie  had  observed  it  in  LO  oul  of  28  uteri  of  young  persons  which 
he  had  examined.  Still  more  rarely,  the  entire  vaginal  portion  may  be 
covered  by  cylindrical  epithelium,  which  may  even  extend  down  over  the 
vagina]  walls.  This  anomaly  was  first  described  by  Huge  in  a  case  of 
imperforate  hymen,  associated  with 
Jicemato-kolpos,  in  which  the  entire 
vagina  and  the  inner  surface  of  the 
hymen  were  covered  by  a  single  layer 
of  columnar,  ciliated  epithelium. 

Corpus  Uteri. — The  wall  of  the 
uterine  body  is  made  up  of  three  lay- 
ers: serous,  muscular,  and  mucous. 
The  serous  layer  is  formed  by  the  peri- 
tonaeum covering  the  uterus,  to  which 
it  is  firmly  adherent  except  at  the 
margins,  where  it  is  deflected  to  the 
broad  ligaments. 

Endometrium. — The  innermost  or 
mucous  layer,  which  serves  as  a  lining 
for  the  uterine  cavity,  is  commonly 
known   as   the    endometrium, 
a   thin,   pinkish,   velvety   membra 
which   on  close   examination 
to  be  perforated  by  large  numbers  of 
minute  openings — the  mouths 
uterine  glands.     On   account 
constant  changes  to  which  it 
ject  during  the  sexual  life  of 
the  endometrium  varies  markedly 
thickness,    and    may    measure    any- 
where from  0.5  to  2  or  3  millimetres 
without  being  necessarily   abnormal. 
It   consists   of  a  surface  epithelium, 
glands,  and  interglandular  tissue,  in 
which  are  found  numerous  bloTrd-ves- 
sels  and  lymphatic  spaces. 

As  the  endometrium  does  not  pos- 
sess a  submucosa,  it  is  attached  directly  to  the  underlying  muscular  layer 
in  such  a  manner  that  its  outer  boundary  presents  irregularities  in  out- 
line corresponding  with  the  interstices  between  the  muscle  bundles.  This 
arrangement  is  of  considerable  importance  in  connection  with  the  opera- 
tion of  curettage;  for,  as  Diivelius  and  AVerth  have  shown,  it  is  from  the 
portions  included  between  the  muscle  bundles  that  the  endometrium  is 
regenerated  after  the  procedure. 

The  surface  epithelium  of  the  uterine  mucosa  is  composed  of  a  single 


Fig.  -i>5. — Cervical  Gland. 


40 


OBSTETRICS 


K 


layer  of  high  columnar  ciliated  cells,  which  are  closely  packed  together. 
The  oval  nuclei  are  situated  in  the  lower  portions  of  the  cells,  but  not 

so  near  their  bases  as  in  the  cervix!     He- 

neath  the  epithelium  is  a  thin  basement 

/ \^i  /  \  membrane    with    narrow,    spindle-shaped 

'-"--^zzzzzzj^<:^^ _V,:-       nuclei. 

J.^---.-.'.'^ ,-'~'    -.<!.'.  The  existence  of  cilia  was  first  demon- 

strated by  Nylander  in  the  sow,  but  they 
V         \  /     ^/  j  have  since  been  found  in  nearly  all  animals. 

: -  ■/-       *  /  Although  Wyder  stated  that  they  were  not 

present  in  the  new-born  child,  the  recent 
researches  of  Meyer  show  that  they  are 
demonstrable  at  variable  periods,  being- 
sometimes  present  at  birth,  but  sometimes 
not  appearing  until  much  later.  They  per- 
sist throughout  the  entire  period  of  sexual 
activity,  and,  according  to  Parviainen,  dis- 
appear eight  or  ten  years  after  the  meno- 
pause. 

Up  to  1893,  it  was  generally  taught  that 
the  current  produced  by  them  was  directed 
from  below  upward — namely,  from  the  cer- 
vix towards  the  fundus;  but  Hofmeier  conclusively  demonstrated  that  it 
is  in  the  opposite  direction,  and  his  researches  have  since  been  confirmed 


Fig.  47. — Keconstruction  of  Uterus, 
showing  Shape  of  Uterine  Cavity 
and  Cervical  Canal.     X  1. 


"V™*  """*"!  /""""""■">  i*T3\ 


„,<"--*-. „. 


X-^>. 


a-.-* 


&s$r5fc2 


M  i 


^, 


U.i-    ff)   ■' 


III 

:    '.,\>r.  -  >->.•  '■   ■    ' 

■■. -n     '  -   t\  -      ^         v-  \    -.  » 
//    ;  r   '■■■'  :>-,'■■  — 

f     <     •■•,   ■;    *>..-- ,-  ' 

•-.  ■-    X«?    ■•.;:.    • 
.■;■•..'- '-;y!s>-- ■.'--••'-.-     '»-:•■' fev".  .'     ■■    .  .  V ■•■■,'■.  ".-^'■•■.'^■.'.■'v..,i 


Fig.  48. — Normal  Endometrium.     X  16. 


by  Mandl.    It  may  therefore  be  considered  as  a  definitely  established  fact 
that  the  ciliary  current  in  both  the  tubes  and  the  uterus  is  in  the  same 


THE    XON   PKKONANT    ITE1UTS 


41 


direction,  and  extends  downward  from  the  fimbriated  end  of  the  tubes  to 
the  external  os. 

In  very  < '  x  t  -  <  ■  i  >  t  i  <  >  l ) ;  1 1  instances,  the  uterine  cavilv  may  I  ><  ■  lined  \>y  strati-, 
lied  (■pTTTuTTiliiju  as  in  the  caSes  reported  by  Zeller  and   P.   Priedlander. 


muscle 


Fig.  49. — Endometrium  or  Newly  Born  Child.     X  150. 

Such  a  condition  readily  explains  the  possible  occurrence  of  flat-celled  car- 
cinoma of  the  body  of  the  uterus. _ 

Projecting  down  from  the  surface  of  the  endometrium  are  large  num- 
bers of  small  tubular  glands — the  uterine  glands.  These  must  be  regarded 
as  mere  invaginations  of  the  surface  epithelium  and  resemble  the  fingers 
of  a  glove,  though  occasionally  they  branch  slightly  at  their  deeper  ex- 


mucosa  s 


muscle 


"fc."^VNv.fci\.\,-4.^ue  ,y  t 

Fig.  50. — Senile  Endometrium.     X  17. 


tremities.  Thev  extend  through  the  entire  thickness  of  the  endometrium 
to  the  muscular  layer,  which  they  occasionally  penetrate  for  a  short  dis- 
tance. They  present  the  same  histological  structure  as  the  surface  epi- 
thelium, and  are  lined  by  a  single  layer  of  high,  columnar,  ciliated  epithe- 


42 


OBSTETRICS 


Hum,  which  rests  upon  a  thin  basement  membrane.  They  secrete  small 
quantities  of  a  thin,  alkaline  secretion,  which  serves  to  keep  the  uterine 
cavity  moist. 

In  studying  microscopic  sections,  it  must  be  remembered  that  the  glands 
are  not  always  cut  vertically,  and  that  their  appearance  will  vary  accord- 
ing to  the  direction  of  the  section.  Thus,  they  not  infrequently  appear  as 
round  or  oval  ojjenings,  and  when  hypertrophied  may  present  a  corkscrew- 
like appearance. 

In  the  child  the  uterine  glands  are  mere  shallow  depressions,  which, 
according  to  Kundrat  and  Engelman,  do  not  appear  until  the  third  year; 
but  the  researches  of  Meyer,  which  are  confirmed  by  my  own  studies,  show 
that  they  are  not  infrequently  present  at  birth.    At  the  menopause  the  en- 


^  ^m®>:  ™«&  #'?  «H  #1  &c#* 

Fig.  51. — Uterine  Gland  and  Stroma.     X  420. 


2#  is%,  0*^ 


tire  endometrium  undergoesatrophic  changes;  its  epithelium  becomes 
flatFer,l'tTglands  gradually  disappear,  and  its  interglandular  tissue  takes 
on  a  more  fibrous  appearance  (see  Fig.  50). 

The  portion  of  the  endometrium  lying  between  the  surface  epithelium 
and  the  underlying  muscle,  which  is  not  occupied  by  glands,  is  filled  by  an 
interglandular  tissue  or  stroma  of  an  embryonic  type.  Under  the  micro- 
scope (Figs.  48  and  51)  it  is  seen  to  be  made  up  of  closely  packed  oval  and 
spindle-shaped  nuclei,  around  which  there  is  very  little  protoplasm.  When 
thetissues  are  spreacl  apart  by  oedema,  it  is  readily  seen  that  the  cells  pre- 
sent a  stellate  appearance,  with  branching  protoplasmic  processes  which 
anastomose  one  with  another.  These  cells  are  more  closely  packed  around 
the  glands  and  blood-vessels  than  elsewhere.  Occasionally  larger  or 
smaller  collections  of  round  cells  may  be  seen  between  them,  though  it  is 
uncertain  whether  or  not  these  are  to  be  regarded  as  lymphoid  ngj 


THE   NON   PREGNANT   [JTEEUS  43 

The  exact  nature  of  the  Lnterglandular  tissue  bas  given  rise  to  a  gi 
deal  of  discussion,  concerning  which  the  authorities  are  aol  yel  fully 
agreed.  Minot  Looks  upon  it  as  nothing  but  embryonic  tissue,  while  Nagel 
sees  in  it  a  resemblance  t<>  Lymphoid  tissue,  ami  Arthur  \V.  Johnstone 
Liolds  that  it  is  of  an  adenoid  type.  On  the  other  hand.  Leopold,  Cham- 
pionniere,  Poirier,  and  others  consider  that  it  represents  a  Lymphatic  sur- 
face. According  to  Leopold,  the  "  uterine  inueo.sa  should  he  considered  as  a 
spread-oul  Lymph-gland  (Lymphdrusenflache),  which  doc-  not  contain  true 
lymph  vessels,  hut  consists  of  spaces  Lined  by  endometrium."  There  is  a 
certain  amount  of  evidence  in  support  of  all  id'  these  views,  hut  1  am 
inclined  to  agree  with  Minot  in  considering  it  as  merely  an  einbryonic 
type  of  wnnecthx^t^ssiie^,, 

\\lmiTprepaTations  from  the  endometrium  are  treated  by  appropriate 
methods,  an  abundant  reticulum  can  lie  demonstrated  throughoul  its  en- 
tire extent,  which  forms  the  scaffolding  upon  which  it  is  constructed. 

The  endometrium  contains  many  blood-vessels.  The  arteries  pursue  a 
spiral  course  and  break  up  into  a  capi  llary  net  work  j ust  beneath  the  surface 
epithelium,  from  which  the  blood  is  returned  by  a  few  comparatively  Large 
vessel.-. 

Musculature  of  the  Uterus  —  Myometrium.  —  The  major  part  of  the 
uterus  is  made  up  of  bundles  of  non-striated  muscle,  which  are  united 
by  a  greater  or  lesser  amount  of  connective  tissue,  in  which  are  found  many 
elastic  fibres  (Pick).  On  section  the  uterine  wall  presents  a  thick,  felt-like 
structure,  in  which  definite  layers  cannot  be  distinguished. 

A  great  deal  of  work  has  been  done  upon  the  arrangement  of  the  mus- 
culature both  of  the  pregnant  and  non-pregnant  uterus.  Tarnier  and 
Ribemont-Dessaignes  were  unable  to  make  out  definite  laj^ers  of  muscle 
bundles  in  the  non-pregnant  organ,  while  Bayer,  Kreitzer,  Veit,  and  others 
distinguished  several,  but  did  not  agree  as  to  their  arrangement.  All 
admit,  however,  that  the  greater  part  of  the  uterine  wall  is  made  up  of  a 
mass  of  muscle  which  is  perforated  in  all  directions  by  blood-vessels,  and 
in  which  it  is  impossible  to  make  out  any  definite  arrangement  of  the 
bundles — stra  1  it  in  vasculare. 

Eoesger  studied  the  question  from  a  developmental  point  of  view,  and 
demonstrated  that  the  muscle  fibres  are  developed  along  the  course  of  the 
blood-vessels,  but  failed  to  distinguish  any  definite  arrangement.  Similar 
studies  by  Werth  and  Grusdew  go  to  show  that  the  musculature  of  the 
foetal  and  infantile  uterus  presents  a  very  simple  arrangement,  which 
becomes  much  more  complicated  as  puberty  is  approached.  During  gesta- 
tion, on  the  other  hand,  the  uterus  undergoes  marked  hypertrophy,  when 
it  becomes  possible  to  distinguish  certain  distinct  layers  which  will  be  con- 
sidered in  the  chapter  on  the  changes  incident  to  pregnancy. 

Ligaments  of  the  Uterus. — Extending  from  either  half  of  the  uterus 
are  three  ligamentous  structures — the  broad,  round,  and  utero-sacral  liga- 
ments (ligamenta  lata,  teretia,  and  utero-sacralia). 

The  broad  ligaments,  or  lir/amenta  lata,  are  two  wing-like  structures 
which  extend  from  the  lateral  margins  of  the  uterus  to  the  pelvic  walls, 
and  serve  to  divide  the  pelvic  cavity  into  an  anterior  and  a  posterior 


44 


OBSTETRICS 


compartment.  Each  broad  ligament  consists  of  a  fold  of  peritonaeum 
inclosing  various  structures  within  it,  and  presents  four  margins  for  ex- 
amination— a  superior,  lateral,  inferior,  and  median.  The  superior  mar- 
gin, for  its  inner  two  thirds,  is  occupied  by  the  Fallopian  tube,  while 
its  outer  third,  extending  from  the  fimbriated  end  of  the  tube  to  the 
pelvic  wall,  is  known  as  the  infundib u lo-pelvic  lirja men t — the  suspensory 
ligament  of  the  ovary  (Henle) — and  serves  to  "transmit  The  ovarian  vessels^ 
The  portion  of  the  broad  ligament  beneath  theTallopian  tube  is  called 
tlie  mesosalpinx,  and  consists  of  two  layers  of  peritonaeum  which  are  united 
by  a '  small  Untount  of  loose  connective  tissue,  in  which  is  embedded  the 
parovarium  or  organ  of  Eosenmiiller  (see  Fig.  41). 

At  its  lateral  margin,  the  peritoneal  covering  of  the  broad  ligament 
is  reflected  upon  the  side  of  the  pelvis.  The  inferior  margin,  which  is 
quite  thick,  is  continuous  with  the  connective  tissue  of  the  pelvic  floor. 
Through  it  pass  {lie  uterine  vessels.     Its  lower  portion — the  cardinal  liga- 


ment of  Kocks  or  the  ligumgn h{nu tra iis- 
veTsale^o^oi  Mackenrodt — is  composed 
of  dense  connective  tissue  which  is  firm- 
ly united  to  the  supravaginal  portion  of 
the  cervix.  The  median  margin  is  con- 
nected with  the  lateral  margin  of  the 
uterus,  and  incloses  the  uterine  vessels;  ( 
through  it  certain  muscular  and  con- 
nective tissue  bands  extend  from  the/ 
uterus  into  the  broad  ligament. 

A  vertical  section  through  the  ute- 
rine end  of  the  broad  ligament  is  trian- 
gular in  shape,  with  the  apex  directed 
upward,  while  its  base  is  broad  and  con- 
tains the  uterine  vessels;  it  is  widely 
connected  with  the  connective  "tissue 
covering  the  pelvic  floor  and  lying  be- 
hind the  bladder,  which  is  designated  as 
the  pQ%ametr\um.  A  vertical  section  through  the  middle  portion  of  the 
broad  ligament  shows  that  its  upper  part  is  made  up  mainly  of  three  branches 
in  which  the  tube,  ovary,  and  round  ligament  are  situated,  while  its  lower 
portion  is  not  so  thick  as  in  the  previous  section. 

The  roundli  gjiment,  or  lupvpienfym  fores,  evteuds  from  the  anterior  and 
lateral  portions  of  the  uterus,  just  below  the  insertion  of  the  tubes.  It  lies 
in  a  fold  of  the  broad  ligament  and  runs  in  an  upward  and  outward  direc- 
tion to  the  inguinal  canal,  through  which  it  passes,  to  terminate  finally  in 
the  upper  portion  of  the  labium  majus.  The  round  ligament  varies  from 
3  to  5  millimetres  in  diameter;  it  is  composed  of  connective  tissue  and  a 
certain  amount  of -non-striated  muscle,  which  is  directly  continuous  with 
that  of  the  uterine  wall.  In  the  nonpregnant  condition  it  appears  as  a  lax 
cord,  but  in  pregnancy  it  undergoes  considerable  hypertrophy  and  seems  to 
act  as  a  stay  for  the  uterus.  It  can  be  palpated  during  pregnancy,  and  by 
its  varying  position  aids  us  in  diagnosing  the  location  of  the  placenta. 


pectum 

Fig.  52. — Section  through  Uterine  End 
of  Broad  Ligament.     X  §. 


THE   STON-PREGNANT   UTERUS  t5 

The  utero-sacral  ligaments — retractores  uteri  JTiimphka.) — are  two  struc- 
tures whicn  extend  from  the  u^mt  |  »<  >m  i<  »ii  n(  tin-  c-»-r\  i.\.  *-nrirele  the 
ririuin.  and  are  inserted   int"  the  fascia  rovrrin;:  tin-  Mrmul  ami  third 

>;U|-;ll     Vrr|rlirn\        Tlli'V     are     lik'cui-r     C<  HI  1 1  n  >-.  -i  I     of     i-»H  11.  -ct  1  Y<-     tisSUe     Illl'l 

muscle,  and  are  covered  bv  peritonaeum.    They  form  the  lateral  boundaries 
of  I  ><»iiu-la.~'s  nil-,/,--*,!,-,  and  are  believed  to  play  a  part   in  retaining  the  I 
uterus  in  its  normal  position  by  exerting  traction  upon  the  cervix. 

Position  of  the  Uterus. — After  many  years  of  discussion,  anatomists 
and  gynaecologists  have  agreed  that  the  normal  position  of  the  uterus, 
whether  pregnant  or  not,  is  one  of  dLdrt  anteflexion.  With  the  woman 
standing  upright,  the  uterus  occupies  an  almost  horizontal  position  and 
is  somewhat  bent  upon  its  vesical  surface,  the  fundus  resting  upon  the 
-  rior  surface  of  the  bladder,  while  the  cervix  is  directed  backward  to- 
wards the  sacrum  (see  Fig.  25).  The  position  of  the  organ  varies  mark- 
edly according  to  the  degree  of  distention  of  the  bladder  and  rectum,  but 
when  these  are  empty  the  uterus  always  tends  to  resume  its  normal  position. 

The  causes  which  bring  about  its  anteflexed  position  have  not  as  yet 
been  definitely  determined.  Normally,  as  long  as  it  is  in  situ,  the  organ 
is  anteflexed,  but  when  removed  from  the  body  it  immediately  straightens 
out.  Schauta  would  attribute  the  anteflexion  to  the  action  exerted  by  the 
ssels  when  filled  with  blood,  but  his  explanation  does  not  appear  alto- 
gether satisfactory.  According  to  Nagel  and  most  embryologists,  the  ante- 
flexion exists  from  the  earliest  stages  of  development,  and  is  to  be  ac-J 
counted  for  by  the  fact  that  the  entire  body  is  developed  along  a  curved  I 
line.  The  pressure  of  the  intestines  upon  the  uterus  is  also  believed  to  play 
a  part,  as  the  light  corpus  is  readily  movable:  while  the  comparatively  large 
cervix  is  held  in  a  fixed  position  by  the  small  pelvis. 

The  uterine  ligaments  were  formerly  supposed  to  play  an  important  part 
in  maintaining  the  uterus  in  its  characteristic  position.  "We  have  already 
indicated  the  functions  of  the  round  and  utero-sacral  ligaments.  The  itpper 
portion  of  the  broad  ligament  appears  to  have  no  influence  upon  the  position 
of  the  uterus,  since  Mackenrodt  has  demonstrated  that  it  can  be  cut  through 
without  causing  any  change  in  position,  which  only  occurs  when  its  deeper 
portion — the  li.gajJientum  transversale  colli — is  divided. 

Blood-vessels  of  the  Uterus. — The  vascular  supply  of  the  uterus  is  de- 
rived from  two  sources :  principally  from  the  uterine  and  to  a  lesser  extent 
from  the  ovarian  ATtPrip;      The  uterine  artery  is  the  main  branch  of  the 
hypogastric,  which,  after  descending  for  a  short  distance,  enters  the  base 
of  the  broad  ligamerrt    crosses  the  ureter,  and  makes  its  way  to  the  - 
of  the   uterus.     Just  before   reaching  the   supravaginal    portion    of   the 
cervix,  it  divides  into  a  larger  and  a  smaller  branch,  the  latter — the  eervico-  \ 
vaginal  artery — supplying  the  lower  portion  of  the  cervix  and  the  upper  \ 
portion  of  the  vagina.     The  main  branch  turns  abruptly  upward  and  ex- 
tends its  a  very  convoluted  vessel  along  the  margin  of  the  uterus,  giving 
off  a  branch  of  considerable  size  to  the  upper  portion  of  the  cervix,  and 
numerous  smaller  ones,  which  penetrate  the  body  of  the  ttterus.     Just 
before  reaching  the  tube  it   divides  into  three   terminal   branches — the 
fundal,  tubal,  and  ovarian — the  last  of  which  anastomoses  with  the  ter- 


46 


OBSTETRICS 


minal  branch  of  the  ovarian  artery;  the  second,  making  its  way  through  the 
mesosalpinx,  supplies  the  tube,  and  the  fundal  branch  is  distributed  to  the 
upper  portion  of  the  uterus. 


Fig. 


—Blood  Supply  oe  Uterus  (Kelly). 


The  ovarian  or  internal  spermatic  artery  is  a  branch  of  the  aorta  and 
enters  the  broad  ligament  througlTThT  inf unclibulo-pelvic  ligament.     On 


THE    NON   PREGNANT    UTERUS 


J  7 


reaching  the  hilum  of  the  ovary  ii  breaks  up  into  a  number  of  small 
branches  which  enter  the  organ,  while  its  main  stem  traverses  the  entire 
length  of  the  broad  ligament  and  makes  its  way  to  the  upper  portion  of 
the  margin  of  the  uterus,  where  it  anastomoses  with  the  ovarian  branch 

of  the  uterine  artery. 

It  is  generally  stated  thai  there  is  very  little  communication  between 

the  vessels  on  the  two  sides  of  the  uterus,  hul  the  recent  experiments  of 
Clark  have  positively  demonstrated   that   such   is  not  the  case.     This  ob- 


Fig.  54. — Lymphatics  of  Uterus  i, Kelly). 

server  found  that  when  the  uterine  artery  on  one  side  was  injected,  the 
fluid  escaped  from  the  opposite  uterine  artery  before  it  began  to  flow  from 
the  veins,  thus  indicating  the  presence  of  numerous  arterial  anastomoses  in 
the  substance  of  the  uterus. 

The  veins  from  the  uterus  form  an  abundant  plexus  around  each 
uterine  artery,  and  unite  to  form  the  uterine  vein  on  either  side,  which 
then  empties  into  the  hypogastric  vein,  which  makes  its  way  into  the  in- 
ternal iliac.     The  blood  from  tne  ovary  and  upper  part  of  the  broad  liga- 


48 


OBSTETRICS 


ment  is  collected  by  a  number  of  veins,  which  form  a  large  plexus  within 
the  broad  ligament — the  pampin  if  arm  plexus — the  vessels  from  which  ter- 
minate in  the  ovarian  vein!  The  right  ovarian  vein  empties  into  the  vena 
cava,  while  the  left  empties  into  tlm~"reMl  Vein. 

Lymphatics. — The  careful  work  of~Ce*o"poM,  Poirier,  Bruhns,  and  others 
has  given  us  a  fairly  definite  idea  of  the  lymphatic  system  of  the  uterus. 


Fig.  55. — XEEvors  Gax&lia  of  Peegxaxt  Utercs  fTrankenhauser). 
A,  plexus  uterinus  magnus  ;  B,  plexus  hypogastrics  ;    C,  cervical  ganglion. 

The  endometrium  is  abundantly  supplied  with  lymph  spaces,  but  pos- 
sesses no  true  Jwnrphatic  vessels.  Immediately  beneath  it  in  the  muscu- 
laris  a  few  lymphatics  may  be  found,  which  become  better  defined  as  the 
peritonaeum  is  approached,  and  form  an  abundant  lymphatic  plexus  just 
■beneath  it,  which  is  especially  marked  on  the  posterior  or  intestinal  wall 
of  the  uterus. 

The  lymphatics  from  the  various  portions  of  the  uterus  are  connected 


THE   NON-PREGNANT   UTERUS  4'.' 

with  several  sets  of  glands — those  of  the  cervix  terminating  in  the  iuiiiir-V 

gastric  uihuMs.  which  arc  situated  in  the  spaces  between  the  external  iliac  \ 
and  hypogastric  arteries.  The  lymphatic-  i'r<iin  tin-  body  of  the  uterus 
are  distributed  to  two  groups  of  glands,  one  sel  of  vessels  making  their 
way  to  the  hypogastric  glands^  while  another  set,  after  joining  certain 
lymphatics  from  ihc  ovarian" region,  terminate  in  the  Lumbar  glands, 
which  are  situated  in  fronl  of  the  aorta  at  about  the  level  ot  tnS  low! 
portion  of  the  kidneys  (see  Fig.  54). 

Innervation. — The  nerve  supply  of  the  uterus  is  derived  partly  from 
the  ceirlmj^iwrrh  but  principally  from  the  sympathetic  ihtvmii-  .-v-iem. 
The  cerebro-spinal  system  is  represented  by  a  few  fibres  from  the  third, 
and  fourth  sacral  nerves,  and  Herlizka  has  lately  demonstrated  the  pres- 
ence of  medullated  nerve-fibres  in  the  uterine  wall,  which  showed  free 
endings  between  the  muscle  bundle-. 

The  greater  portion  of  the  nerve  supply,  however,  is  derived  from  the 
sympathetic  system,  and  has  been  studied  particularly  by  Lee,  Franken- 
haiiser,  and  Rein.  According  to  these  authors,  large  nerve-trunks  from 
the  inter-iliac  plexus  pass  down  on  either  side  of  the  rectum,  and  following 
the  course  of  the  utero-sacral  ligaments,  terminate  in  the  large  cervical 
ganglion.  This  structure  was  first  discovered  by  Lee:  it  lies  to  the  side 
of 'dlid  behind  the  cervix,  and  from  it  numerous  fibres  make  tbeir  way  to 
the  uterus,  as  is  readily  seen  in  Fig.  55. 

Herff  and  Gawronsky  have  recently  described  ganglionic  cells  in  the 
museularis.  and  the  latter  has  been  able  to  follow  isolated  nerve-fibres  into 
the  epithelial  cells  of  the  endometrium. 

Development  of  the  Uterus. — It  is  universally  admitted  by  embryolo- 
gists  that  both  the  tubes  and  the  uterus  are  derived  from  the  Miillerian 
ducts.  According  to  His.  the  first  signs  of  their  development  can  be  noted 
in  embryos  having  a  body  length  of  from  T  to  7.5  millimetres,  when  a 
thickening  may  be  noticed  in  the  ccelomic  epithelium  on  the  outer  margin 
of  each  Wolffian  body.  These  gradually  become  converted  into  two  epi- 
thelial ducts,  which  converge  and  eventually  meet  together  in  the  middle 
line,  terminating  in  the  uro-genital  sinus. 

The  Miillerian  ducts  reach  the  uro-genital  sinus  in  embryos  having 
a  body  length  of  2.5  to  3.5  centimetres.  Their  upper  ends  form  the  Fal- 
lopian tubes,  while  their  lower  portions  fuse  together  to  form  the  uterus 
and  vagina.  The  fusion  of  the  Miillerian  ducts  is  usually  completed  at 
about  the  third  month,  though  the  point  at  which  the  process  is  to  occur 
is  indicated  at  a  much  earlier  period  by  the  position  of  the  round  liga- 
ments. 

LITERATURE 

Bayer.     Zur  physiol.  und  path.  Morphologie  der  Gebarmutter.    Fremiti's  Gynakologische 

Klinik,  1885.  369-662. 
Bruhns.    Ueber  die  Lymph sefasse  der  weiblichen  Genitalien.    Archiv  f.  Anat.  u.  Physiol., 

Anat.  Abtbeil,  1898.  57. 
Champioxxiere.     Les  lymphatiques  uterines.     Paris.  1875. 
Clark.     The  Causes  and  Significance  of  Uterine  Hemorrhage  in  Cases  of  Myoma  Uteri. 

Johns  Hopkins  Hospital  Bulletin.  1899.  11-20. 


50  OBSTETRICS 

Duvelius.     Zur  Kenntniss  der  Uterusschleimhaut.    Zeitschr.  f.  Geb.  u.  Gyn.,  x,  175-187, 

1884. 
Engelman.     The   Mucous   Membrane   of   the   Uterus.     Amer.   Jour.    Obst.,   viii,   30-86, 

1875. 
Fischel.     Beitrage  zur   Morphologie   der  Portio  vaginalis   uteri.     Archiv  f.  Gyn.,  xvi, 

192-202,  1880. 
Frankenhauser.     Die  Nerven  der  Gebarmutter.     Jena,  1867. 
Friedlander,  G.     Phys.  anat.  Untersuehungen  iiber  den  Uterus.     Leipzig,  1870. 
Friedlander,  F.     Abnorme  Epithelbildung  im  kindlichen  Uterus.     Zeitschr.  f.  Geb.  u. 

Gyn.,  xxxviii,  8-16,  1898. 
Gawronsky.    Ueber  Verbreitung  und  Endigung  der  Nerven  in  den  weiblichen  Genitalien. 

Archiv  f.  Gyn.,  xlvii,  271-283,  1894. 
Herff.     Ueber  das  anat.  Verhalten   der   Nerven   in   dem    Uterus,   etc.      Munch,   med. 

Wochenschr.,  Nr.  4,  1892. 
Herlizka.     Quoted  by  Joessel-Waldeyer,  Das  Becken.     Bonn,  1899,  764. 
His.     Die  anatomische  Nomenclatur.     Leipzig,  1895. 
Hofmeier.     Zur  Kenntniss  der  normalen  Uterusschleimhaut.    Centralbl.  f.  Gyn.,  764-766, 

1893. 
Johnstone.     The  Menstrual  Organ.    Brit.  Gyn.  Jour.,  November,  1886. 

The  Function  and  Patholog    of  the  Reticular  Tissue.    Amer.  Gyn.  and  Obst.  Jour.,  ix, 

166-187,  1896. 
Kocks.     Die  normale  und  path.  Lage  des  Uterus,  etc.     Bonn,  1880. 
Kreitzer.     Anatomische  Untersuehungen  iiber  die  Muskulatur  der  nicht  schwangeren 

Gebarmutter.     Petersburger  med.  Zeitschrift,  1871,  113. 
Lee.     The  Anatomy  of   the  Nerves   of   the  Uterus.     Philosophical  Transactions,  1841, 

1842,  1846. 
Leopold.     Die  Lymphgefasse  des  normalen,  nicht  schwangeren,  Uterus.     Archiv  f.  Gyn., 

vi,  1-55,  1874. 
Studien  iiber  die  Uterusschleimhaut.     Berlin,  1878. 
Luschka.     Die  Anatomie  des  Beckens.     Karlsruhe,  1873. 
Mackenrodt.     Ueber  die  Ursaehen  der  normalen  und  path.  Lagen  des  Uterus.     Archiv 

f.  Gyn.,  xlviii,  393-421,  1895. 
Mandl.     Ueber  die  Richtung  der  Flimmerbewegung  im  menschlichen  Uterus.    Centralbl. 

f.  Gyn.,  1898,  322-328. 
Meyer.     Ueber  die  fotale  Uterusschleimhaut,    Zeitschr.  f.  Geb.  u.  Gyn.,  xxxviii,  234-249, 


Minot.     Human  Embryology,  3,  1892. 

Nagel.     Die  weiblichen  Geschlechtsorgane  (Bardeleben's  Handbuch  der  Anatomie),  Jena, 

1896,  87-90. 
Parviainen.     Zur  Kenntniss  der  senilen  Veranderungen  der  Gebarmutter.     Berlin,  1897. 
Pick.     Ueber  das  elastische  Gewebe  in  der  normalen  und  path,  veranderten  Gebarmutter. 

Volkmann's  Sammlung  klin.  Vortrage,  N.  F.,  Nr.  283,  1900. 
Poirier.     Lyinphatiques  des  organes  genitaux  de  la  femme.     Paris,  1890. 
Rein.     Notes  sur  le  plexus  nerveux  fondamental  de  l'uterus.     Comptes  rendus  de  la  Soc. 

de  Biologie,  1882,  161. 
Ribemont-Dessaignes.     Precis  d'obstetrique,  30.     Paris,  1894. 
Roesger.   Zur  fotalen  Entwickelung  des  menschlichen  Uterus.  Festschrift  zum  50-jahrigen 

Jubilaum  der  Gesellsch.  f.  Geb.  u.  Gyn.  in  Berlin,  9-52,  1894. 
Ruge.     Zur  Erosionsfrage.     Zeitschr.  f.  Geb.  u.  Gyn.,  vii,  231-233,  1882. 
Schauta.     Lehrbuch  der  gesammten  Gynakologie,  Wien,  1896,  5-14. 
Tarnier.     Trade  de  l'art  des  accouehements.     T.  I.,  106.  Paris,  1888. 

Veke Tterusmuskulatur.     Midler's  Handbuch  der  Geburtshiilfe,  i,  122-129,  1888. 

Werth.     Untersuehungen  iiber  die  Regeneration  der  Schleimhaut  nach  Ausschabung  der 

Uteruskorperhohle.     Archiv  f.  Gyn.,  xlix,  369,  370,  1895. 


TIIK    FALLOPIAN    TUBES 


51 


Weeth  urn!  Grusdew.  Untersuchungen  aber  die  Entwickelung  and  Morphologic  der 
menschlichen  tJterusmuskulatur.     Archiv  1".  Gyn.,  Iv,  325-413,  L898. 

\\'\  dee.  Beitrage  zur  normaled  u.  path.  Histologic  der  menschlichen  Qterusschleimhaut. 
Archiv  f.  Gyn.,  xiii.  1-56,  1878. 

Zellee.     PlattenepitheJ  im  CTterus.    Zeitschr.  r.  Geb.  u.  Gyn.,  xi,  56-88,  1885. 

THE     FALLOPIAN    TUBES 

The  Fallopian  or  uterine  tubes  are  more  or  less  convoluted  muscular 
canals  which  extend  from  the  uterine  cornua  to  the  ovaries.  They  are 
covered  by  peritonaeum  and  possess  a  lumen  lined  by  mucous  membrane. 
They  represent  the  excretory  ducts  of  the  ovaries,  as  it  i-  through  them  that 
the  ova  gain  access  to  the  uterine  cavity.  They  are  more  or  less  cylin- 
drical in  shape,  and  vary  from  8  to  14  centimetres  in  length. 

For  convenience  in  description,  each  tube  may  be  divided  into  several 
parts — tin-  uterine  poi;tion,  isthmus,  ampulla,  and   infundibulum.     The 
uterine  portion  is  included  within Ihe  muscular  wall  of  the  uterus,  and  I 
extends  from  the  cornu  to  the  upper  angle  of  the  uterine  cavitv.      rts  ' 
lumen  is  so  small  that  it  will  admit  only  the  finest  probe.     The  isthmus 
is  the  narrow  portion  of  the  tube  immediately  adjoining  the  uterus,  and 
gradually  passes  into  the  wider  lateral  portion  or  ampulla.    The  ii'fumlili- 
ujjl.iu.  or  fimbriated  extremity,  is  the  funnel-shaped  opening  of  the  lat- 
eral  end   of  the   tube, 
the   margins   of  which 
present   a   dentate   ap- 
pearance (see  Figs.  39 
to  41). 

The  tube  varies 
considerably  in  thick- 
ness, the  narrowest 
portion  of  the  isth- 
mus measuring  from 
2  to  3  millimetres,  and 
the  widest  portion  of 
the  ampulla  from  5  to 
7  or  8  millimetres  in 
diameter. 

With  the  exception 
of  its  uterine  portion, 
the  tube,  throughout 
its  entire  length,  is 
included  within  the 
upper  margin  of  the 
broad    ligament:    it    is 

completely  surrounded  by  peritonamm  except  at  its  lower  portion,  cor- 
responding to  the  mesosalpinx.  The  fimbriated  extremity  opens  freely 
into  the  abdominal  cavitv,  and  one  of  its  fimbriae — the  fimbria  ovarica — 
which  is  considerably  longer  than  the  others,  forms  a  shallow  gutter  which 
extends  almost  or  quite  to  the  ovary. 


Fig.  56.— Tubal  Mucosa.     X  280. 


52 


OBSTETRICS 


Generally  speaking,  the  musculature  of  the  tube  is  arranged  in  two 
layers — an  inner,  circular,  and  an  outer,  longitudinal  layer.    In  its  uterine 


Fig. 


Fig.  58. 


;      S: 


m 


- 


g*Sa  ■: 


Fk 


I 


TO^>T%.V<i.« 


Figs.  57-59. — Sections  through  Uterine,  Isthmic,  and  Ampullar  Portions  of  Tube.     X  15. 

portion  a  third  layer,  lying  between  the  circular  layer  and  the  mucosa,  and 
composed  oT  longitudinal  fibres,  may  be  distinguished.    In  the  lateral  por- 


THE    FALLOPIAN   TUBES 


53 


tion  of  the  tube  the  two  primary  Layers  become  less  marked,  and  in  the 
neighbourhood  of  the  fimbriated  extremity  arc  replaced  by  an  interlacing 
networigofjnugcle  fibres.  The  writer  was  the  firs!  to  call  attention  to  the 
presence  of  the  inner  longitudinal  layer  in  the  uterine  portion  of  the  tube, 
ami  his  observations  have  been  confirmed  by  Ballantyne,  Mamll,  ami 
Grusdew. 

The  lumen  of  the  tube  is  lined  with  a  mucous  membrane  whose  epithe- 
lium is  composed  of  a  single  lnvcr  of  high,  columnar,  cilialed  Lulls,  which 
rest  upon  a  thin_bascnicru  membrane  (Fig.  56).  There  is  uosubmucosa,  the 
epithelium  being  separated  from  the  underlying  muscle  by  a  layer  >>{  con- 
nective tissue  of  varying  thickness. 

The  mucosa  is  arranged  in  folds  which  become  more  complicate)]  as  the 
fimbriated  end  is  approached.  The  appearance  of  the  lumen  varies  accord- 
ing to  the  portion  of  the  tube  examined.  In  the  uterine  portion  four 
elevations  are  seen,  which  together  make  a  figure  resembling  a  Maltese 
cross.     In  the  isthmic  portion  of  the  tube  a  more  complicated  appearance 


Fig.  60. — Loxgitudinal  Folds  of  Tubal  Mucosa  (after  Sappey). 


can  be  noted;  -while  in  the  ampulla  the  lumen  is  almost  completely  occu- 
pied by  the  arborescent  mucosa,  which  upon  careful  examination  is  seen 
to  be  made  up  of  four  very  complicated  tree-like  folds. 

Fig.  60  represents  a  longitudinal  section  through  the  tube,  and  gives  a 
good  idea  of  the  increasing  complexity  of  its  folds. 

The  statements  of  Hennig  and  Bland-Sutton  that  the  tube  possesses 
glands  have  since  been  found  to  be  erroneous,  inasmuch  as  the  struc- 
tures, which  they  considered  as  such,  are  merely  depressions  between 
folds  of  the  mucosa.  The  absence  of  glands  was  conclusively  demon- 
strated  by  Frommel,  who  showed  that  the  glandular  appearance  disap- 
peared when  the  tube  was  markedly  distended,  and  that  the  greater 
part  of  its  lumen  became  perfectly  smooth,  with  four  arborescent  folds 
of  mucosa  arising  from  its  sides.  It  is  interesting  to  note  that  Nature 
not  infrequently  performs  a  similar  experiment  in  cases  of  hydro- 
salpinx. 

The  current  produced  by  the  cilia  of  the  tube  is  directed  towards  the 
uterus,  as  was  conclusively  demonstrated  by  the  experiments  of  Pinner, 
Jani,  and  Lode,  who  showed  that  foreign  bodies  injected  into   the  ab- 


54  OBSTETRICS 

dominal  cavity  of  animals  made  their  way  into  the  tubes  and  were  gradu- 
ally carried  down  into  the  uterus  and  thence  into  the  vagina. 

The  tubes  are  richly  supplied  with  blood-vessels  and  lymphatics,,  and 
the  latter  not  infrequently  become  so  dilated  as  to  fill  up  almost  entirely 
certain  folds  of  the  mucosa. 

Occasionalry,  as  Eichard  first  pointed  out,  the  tube  may  possess  a  sec- 
ond fimbriated  extremity,  which  is  known  as  an  accessory  ostium  (Fig. 
61).  Again,  not  infrequently  small  tube-like  structures,  with  miniature 
fimbriated  extremities,  are  found  projecting  from  the  exterior  of  the  tube. 
As  a  rule,  these  are  mere  culs-de-sac,  but  occasionally  one  is  met  with  pos- 
sessing a  lumen  which  communicates  with  that  of  the  main  tube.  Henrotin 
and  Herzog  have  lately  reported  a  case  of  extra-uterine  pregnane}^  in  which 
the  fertilized  ovum  had  been  arrested  in  such  a  structure. 

Similar  formations  are  frequently  observed  upon  the  anterior  surface 
of  the  mesosalpinx,  but  have  no  connection  with  the  tube.  They  have 
been  studied  more  particularly  by  Kossmann,  who  designated  them  as 


Fig.  61. — TfBE  with  Accessory  Ostium. 

accessori/  tubes.  They  are  probably  derived  from  aberrant  portions  of  the 
ccelomic  epithelium. 

In  very  exceptional  instances  there  may  be  two  tubes  on  one  side, 
as  in  the  cases  reported  by  Pick  and  Both. 

Diverticula  n^  occasionally  extend  from  the  lumen  of  the  tube  for 
a  variable  distance  into  its  muscular  wall,  and  reach  almost  to  its  peritoneal 
covering.  Such  structures  were  first  described  by  Landau  and  Eheinstein 
and  myself.  The  suggestion  that  they  might  play  a  part  in  the  production 
of  tubal  pregnancy  would  seem  plausible,  inasmuch  as  a  fertilized  ovum, 
which  might  chance  to  make  its  way  into  such  a  diverticulum,  would  be 
arrested  at  its  tip  and  there  develop,  if  suitable  conditions  existed.  Similar 
structures  have  also  been  described  by  Henrotin  and  Goebel. 

In  rare  instances  the  main  canal  of  the  tube  may  branch,  and  two  or 
even  three  lumina  may  be  seen  in  sections.  After  extending  for  a  certain 
distance,  more  or  less  parallel  to  the  main  lumen,  they  usually  rejoin  it. 
It  should  always  be  borne  in  mind  that  such  appearances  are  usually  due 
to  the  fact  that  two  or  more  twists  or  bends  of  the  tube  have  been  included 
in  one  section;  although  in  several  instances,  by"  the  use  of  the  serial 
method,  I  have  been  able  to  demonstrate  that  more  than  one  lumen  really 
existed. 


THE  OVARIES 

In  the  new-born  child  the  tubes  arc  markedly  convoluted,  and   pre- 
sent a  corkscrew-like  appearance,  as  shown  in  Fig.  39.    This  gradually  dis- 
appears with  age,  bul  occasionally  the  1'ij-tal  t« >n<  1  i t i« >t t  | >.-i--i ~i -  ami  may 
play  a  n<>t  unimportanl  pari  in  the  production  of  sterility  and  tubal  'li- 
as was  tir-i  pointed  oul  by  Freund  ami  Schober. 

LITERATURE 

r>Ai.i..\NTYM:  and  Williams.     The  Bistology  and   Pathology  <>!'  the  Fallopian  Tubes. 

British  Medical  Journal,  January  IT  and  24.  1891. 
Both.    Rechtsseitige  Tubarschwangerschaft,  etc.    Monatsschr. f .  Geb.  u.  Gyn.,  i.\.  7*2  T'.it. 

Fbommel.     Beitriige  zur  Histologic  dor  Eileiter.     Verh.  der  deutschen  Gesell.  f.  Gyn., 

L886,  95. 
Freund.     Ueber  die  Indicationen   zur  operativen  Behandlung  der  erkrankten  Tuben. 

Volkmann's  Sammlung  klin.  Vortrage,  Nr.  323,  1888. 
Goebel.     Beitrag  zur  Anatomie  und  Aetiologie  der  Graviditas  tubaria,  etc.     Archiv  f. 

Gyn.,  It,  658-713,  1898. 
Grusdew.     Zur  Histologic  der  Fallopia'schen  Tuben.     Centralbl.  f.  Gyn..  L897,  257. 
Hknnig.     CTeber  die  Blindgange  der  Eileiter.     Archiv  f.  Gyn..  xiii.  156,  1878. 
Hkxrotix  et   IIkrzoi;.     Anomalies  du   canal   de  Miiller,   comme   cause  des  gro 

ectopiques.     Revue  de  Gyn..  633-640.  1898. 
Janl     Ueber  das  Vorkorameu  von  Tuberkelbaeillen   im  gesunden  Genitalapparat  bei 

Lungenschwindsucht.  etc.     Virchow's  Archiv.  ciii.  522. 
Kossmann.      Ueber  accessorische   Tuben  und  Tubeuostien.     Zeitschr.  f.  Geb.  u.  Gyn., 

xxix.  253-268,  1894. 
Laxdau  und  Rheixsteix.     Beitrage  zur  path.  Anatotnie  der  Tuben.     Archiv  f.  Gyn., 

xxxix.  073-290.  1891. 
Lode.     Exp.  Beitriige  zur  Lehre  von  der  Wanderung  des  Eies  voru  Ovarium  zur  Tube, 

Archiv  i.  Gyn.,  xlv,  -295-324.  1894. 
Maxdl.     Ueber  den  feineren  Bau   der  Eileiter.  etc.     Monatsschr.  f.  Geb.  u.  Gyn..  v. 

Erganzungs  Heft,  130-140,  1897. 
Pick.     Ein  neuer  Typus  des  voluminosen  paroophoralen  Adenomyoms.     Archiv  f.  Gyn., 

liv.  117-206.  1897. 
Pixxer.     Ueber  den  Eintritt  des   Eies  aus   dem  Ovarium  in  die  Tube.  etc.     Archiv  f. 

Anat.  u.  Phys.,  Physiol.  Abth..  1880.  241. 
Richard.     Pavilions  multiplies.     Gaz.  Med.  de  Paris.  Xo.  26.  1851. 
Schober.     Ueber  Erkrankungen  gewundener  Tuben.     D.  I..  Strassburg.  1889. 
Suttox.     Glands  of  the  Fallopian  Tube  and  their  Function.     Trans.  London  Obst.  Soc, 

xxx.  207-213.  1888. 
Williams.     Contributions  to  the  Normal  and  Pathological  Histology  of  the  Fallopian 

Tubes.     Amer.  Jour.  Med.  Sciences.  October,  1891. 


THE    OVARIES 

General  Anatomy. — The  ovaries  are  two  flattened,  more  or  less  almond- 
shaped  organs,  whose  chief  function  is  the  development  and  extrusion  of 
ova.  They  vary  considerably  in  size,  and  during  the  childbearing  period 
measure  from  2.5  to  5  centimetres  in  length.  1.5  to  3  centimetre-  in 
breadth^  and  0.6  to  1.5  centimetres  in  thickness  (see  Fig.  41).  After  the 
menopause  they  diminish  markedly  in  size,  and  in  old  women  are  often 
scarcely  larger  than  peas. 


56  OBSTETRICS 

formally,  the  ovaries  are  situated  in  the  upper  part  of  the  pelvic 
cavity,  one  surface  of  each  ovary  resting  in  a  slight  depression  in  the 
upper  portion  of  the  inner  surface  of  the  obturator  muscle — the  fossa 
ovarica  of  "Waldeyer.  "With  the  woman  standmgTthe  long  axes  of  the 
ovaries  occupy  an  almost  vertical  position,  which  become  horizontal  when 
she  is  on  her  back.  Their  situation,  however,  is  subject  to  marked  varia- 
tions, and  it  is  rare  to  find  both  ovaries  at  exactly  the  same  level. 

Each  ovary  presents  for  examination  two  surfaces,  two  margins,  and 
two  poles.  The  surface  which  is  in  contact  with  the  ovarian  fossa  is  called 
the  lateral,  and  the  one  directed  towards  the  uterus  is  known  as  the  median 
surface.  The  margin  which  is  attached  to  the  mesovarium  is  more  or  less 
straight,  and  is  designated  as  the  hilum,  while  the  free  margin  is  markedly 
convex  and  is  directed  backward  and  inward  towards  the  rectum.  The  ex- 
tremities of  the  ovary  are  termed  the  upper  and  lower,  or  tubal  and  uterine 
poles  respectively. 

The  ovary  is  attached  to  the  broad  ligament  by  the  mesovarium,  which 
forms  the  posterior  leaf  of  that  structure.  The  qjmrwM  I  i  gam  en?  extends 
from  the  lateral  and  posterior  portion  of  the  uterus,  just  beneath  the 
tubal  insertion,  to  the  uterine  or  lower  pole  of  the  ovary.  It  is  usually 
several  centimetres  long  and  3  to  -i  millimetres  in  diameter.  It  is  covered 
by  peritonaeum,  and  is  made  up  of  muscle  and  connective-tissue  fibres, 
which  are  continuous  with  those  of  the  uterus.  The  in fundibulo- pelvic  or 
suspensory  ligament  of  the  ovary  extends  from  its  upper  or  tubal  pole  to 
the  pelvic  wall.  It  represents  the  portion  of  the  upper  margin  of  the 
broad  ligament  which  is  not  occupied  by  the  tube,  and  through  it  the 
ovarian  vessels  gain  access  to  the  broad  ligament. 

For  the  most  part  the  ovary  projects  freely  into  the  abdominal  cavity, 
and  is  not  covered  bv  peritonaeum  except  near  its  hilum,  where  a  narrow 
band  may  be  observed  wmch  is  continuous  with  the  peritonaeum  cov- 
ering the  mesosalpinx.  It  follows,  therefore,  that  over  its  lower  portion 
only  can  be  noted  the  glistening  appearance  characteristic  of  peritonaeum, 
while  the  greater  part  of  its  surface  is  of  a  dull  white  colour  and  looks 
moist.  This  distinction  was  discovered  by  Farre,  but  its  importance  was 
first  emphasized  by  Waldeyer  (Fig.  66),  who  showed  that  the  ovary  above 
the  peritoneal  line  was  covered  by  cuboidal  epithelium. 

In  many  of  the  lower  animals  the  ovary  does  not  project  freely  into 
the  abdominal  cavity,  but  is  more  or  less  completely  inclosed  in  a  peri- 
toneal sac,  into  which  opens  the  fimbriated  end  of  the  tube.  In  the 
cow,  dog,  and  cat  there  is  more  or  less  free  communication  between  it  and 
the  peritoneal  cavity. 

The  exterior  of  the  ovary  varies  in  appearance  according  to  the  age  of 
the  individual.  In  young  women  the  organ  presents  a  smooth,  dull  white 
surface,  through  which"  glisten  a  number  of  small,  clear  vesicles — the 
Graafian  follicles.  As  the  woman  grows  older  it  takes  on  a  more  cor- 
rugated appearance,  which  in  the  aged  may  become  so  marked  as  to  be 
suggestive  of  the  convolutions  of  the  brain. 

The  general  structure  of  the  ovary  can  best  be  studied  in  cross-sec- 
tions, when  the  organ  is  seen  to  be  made  up  of  two  portions:  the  cortex  and 


THE   OVARIES 


57 


medulla,  or  zona  parenchymatosa  and  zona  vasculosa.  The  corter.  nr  nyter 
layer  varies  in  thickness  according  to  the  age  of  the  individual,  becom- 
ing thinner  with  advancing  years.     In  this  Layer  the  ova  and  Graafian  iol- 

luii^aiv  situated.  It  is  composed  of  >i>i mile-shaped  connective-tissue 
cells,  through  which  are  scattered  pri- 
mordial and  Graalian  follicles  in  various 
stages  of  development,  which  become  less 
numerous  as  the  woman  grows  older. 
The  most  external  portion  of  the  cortex 
presents  a  dull  whitish  appearance,  and  is 
designated  as  the  albuginea;  <>n  its  sur- 
face is  a  single  layer  of  cuboidal  epithe- 
lium— the  ovarian  epithelium  of  Wal- 
deyer. 

The  iiiedyHjz  01*  central  portion  of  the 
ovary  is  composed  of  loose  connective 
tissue,  which  is  continuous  with  that  of 
the  mesovarium.  It  contains  large  num- 
bers of  blood-vessels,  both  arteries  and 
veins:  and.  according  to  His,  Kollicker, 
and  Rouget.  a  considerable  number  of 
non-striated  muscle-fibres,  whose  pres- 
ence caused  the  last-named  observer  to 
class  it  among  the  erectile  tissues.  The 
arrangement  of  the  blood-vessels  has 
lately  been  studied  exhaustively  by 
Clark,  to  whose  admirable  monograph 
we  would  refer  those  interested  in  the 
subject. 

In  the  neighbourhood  of  the  hilum, 
epithelial  structures  are  occasionally  ob- 
served which  consist  of  short  tubes  or 
ducts  lined  by  a  single  layer  of  columnar,  ciliated  epithelium.  These  are 
the  medulla ri/j/n rds  ( Markstrange)  of  Kollicker,  and  represent  portions  of 
the  Wolffian  body  which  have  become  included  within  the  ovary. 

The  nerves  of  the  ovary  are  derived  in  great  part  from  the  sympathetic 
plexus  which  accompanies  the  ovarian  artery,  while  a  few  are  derived  from 
the  plexus  surrounding  the  ovarian  branch  of  the  uterine  artery.  Their 
finer  anatomy,  after  they  enter  the  ovary,  has  lately  been  studied  by  nu- 
merous investigators,  among  whom  may  be  mentioned  Von  Herff.  Gaw- 
ronsky,  Mandl,  "vVinterhalter,  and  Vallet.  The  consensus  of  these  re- 
searches shows  that  the  ovary  is  very  richly  supplied  with  non-rnedullated 
nerve-fibres,  which  for  the  most  part  accompany  the  blood-vessels,  and 
are  merely  vascular  nerves:  whereas  a  few  form  wreaths  around  the  fol- 
licles and  give  off  many  minute  branches,  which  have  been  traced  up  to, 
hut  not  through,  the  membrana  granulosa. 

Elizabeth  Winterhalter  has  described  a  collection  of  ganglionic  cells 
in  the  medulla  of  the  ovarv  which  she  desisjtates  as  the  ovarian  gang-lion. 


Fig.  62. — Cross-sectiox   Adult   Ovary, 
SHOwi>-(i  Graafian  Follicles.     X  4. 


58 


OBSTETRICS 


G.E. 


P.O.. 


a— 


She  believes  that  these  cells  play  an  important  part  in  the  production  of 
menstruation,  although  the  majority  of  investigators  do  not  share  her 
views. 

Accessory  Ovaries. — "Waldeyer,  in  1870,  directed  attention  to  the  occa- 
sional presence  of  accessory  bodies  which  are  sometimes  found  on  the 
broad  ligament  in  the  neighbourhood  of  the  main  ovary.  These  structures 
are  usually  small,  although  in  rare  instances  they  may  attain  a  consider- 
able size.  Occasionally  they  result  from  faulty  development,  but  more 
frequently  are  to  be  attributed  to  inflammatory  changes  occurring  during 
foetal  life,  as  a  consequence  of  which  small  portions  of  the  ovary  have 
been  cut  off  from  the  body  of  the  organ.  The  subject  has  lately  been 
considered  in  detail  by  Engstrom  and  Thumin,  the   latter  stating  that 

Keppler  and  Falk  have  de- 
;'  /<•'/  scribed  cases  in  which  there 

was   found   a  typical  third 
ovary    connected   with    the 
uterus  by  a  separate  tube. 
-  AW.  Transplantation  of  Ova- 

ries. — Experimental  studies 
undertaken  recently  by  G-ri- 
gorieff,  Morris,  Knauer,  and 
others  have  shown  that  the 
ovaries  of  animals  and  wom- 
en may  be  excised  from 
their  original  position  and 
transplanted  to  other  por- 
tions of  the  body,  and  that 
in  their  new  situation  they 
can  establish  vascular  con- 
nections and  continue  their 
functional  activity.  In  sev- 
eral cases  pregnancy  has 
followed  the  operation  in 
animals. 

Internal  Secretion. — 
From  the  time  that  Brown- 
Sequard  published  his  studies  upon  the  secretion  of  the  testicles,  it  has  been 
more  or  less  generally  believed  that  the  ovaries  likewise  elaborate  a  some- 
what analogous  product,  which  plays  an  important  part  in  the  female  econo- 
my. Indeed,  Knauer's  recent  work  renders  it  probable  that  this  secretion  is 
directly  concerned  in  maintaining  the  integrity  of  the  other  generative  or- 
gans; inasmuch  as  he  has  shown  that  atrophy  of  the  uterus  and  vagina  rapid- 
ly follows  the  removal  of  the  ovaries,  whereas  this  does  not  occur  when  the 
ovaries  are  removed  from  their  normal  position  and  transplanted  to  other 
portions  of  the  body.  Knauer  therefore  concludes  that  in  such  cases  the 
absence  of  atrophy  must  be  attributed  to  the  action  of  the  internal  secre- 
tion of  the  transplanted  ovaries,  since  all  nerve  connections  were  severed 
at  the  time  of  operation.     Upon  this  same  idea  is  based  the  therapeutic 


Fig.  63. — Section  through  Wolffian  Body  and  Begin- 
ning Ovaky  and  Mulleeian  Duct  (Waldeyer).     X  160. 

A.W.,  abdominal  wall;  G.R,  germinal  epithelium;  M.D.,  be- 
ginning Mullerian  duct;  0.,  beginning  ovary;  P.O.,  pri- 
mordial ova;  W.B.,  Wolffian  body. 


TIIK  ova  1;  u:s 


59 


application  of  ovarian  extracts.   A  full  rrsiunfot  the  literature  dealing  with 
this  subject  is  to  be  found  in  the  thesis  of  Bestion  de  Camboulas  (1898). 

Development  of  the  Ovary. — An  accurate  idea  of  the  structure  of  the 
ovary  can   be  gained   only   through    the  study  of   its  development.     To 
Waldeyer  we  are   indebted    for  most  of  our  knowledge  concerning  the 
subject,   though    im- 
portant    preliminary  ^ 
work   has  been  done 
by     Valentin    and 
l'fliiger. 

In  18  7  0,  Wal- 
deyer published  his 
monograph  upon  the 
Ovary  and  Ovum 
(Eierstock  und  Ei), 
which  was  based  in 
great  part  upon  the 
embryology  of  the 
chicken.  He  found 
that    by    the    fourth 


Fig.  64.- 


-Vertical  Section  through  Ovary  of  Eight-months' 
Foetus  (Waldeyer). 

day  of  development  E.N.,  egg-nests ;  G.R,  germinal  epithelium ;  P.P.,  primordial  follicle. 
the  coelomic  epithe- 
lium covering  the  inner  surface  of  the  Wolffian  body  is  differentiated  from 
the  surrounding  tissue,  its  cells  becoming  larger  and  more  cuboidal  in  shape, 
and  some  of  them  assuming"^  considerable  size.  Within  a  short  time  the 
epithelium  proliferates  to  such  an  extent  as  to  form  a  distinct  elevation, 
which  indicates  the  situation  of  the  future  ovary  (Fig.  63)~  'i'his  epithelium 
Waldeyer  designated  as  germ  in  a  I  epith  elium,  and  the  large,  clear  cells  found 
within  it  as  primordial  ova.  As  the  proliferation  continues,  a  mass  of  cells  is 
formed  consisting  of  large  primordial  ova  and  smaller  germinal  epithelial 
cells.  At  the  same  time,  bands  of  connective  tissue  and  blood-vessels  grow 
upward  from  the  Wolffian  body  and  divide  the  epithelial  mass  into  numer- 
ous smaller  portions,  the 
so-called  egg-balls  or  egg- 
nests. 

Each  egg-nest  at  this 
stage  of  development  con- 
sists of  a  mass  of  primor=. 
dial  ova,  which  are  indis- 
criminately  mixed  with 
smaller  epithelial  cells, 
while  the  surface  or  ger- 


Fig.  65.- 


-Section  through  the  Ovary  of  a  Pig  Embryo 
(Nagel). 
G.E.,  germinal  epithelium  ;  S.,  stroma  of  "Wolffian  body. 

minal  "epithelium  contin- 
ues to  proliferate.  Continued  growth  of  the  connective  tissue  gradually  sub- 
divides the  egg-nests  into  smaller  and  smaller  masses,  until  eventually  iso7 
lated  primordial  ova  are  found  which  are  surrounded  by  a  single  layeroXmore. 
or  less  flattened  epithelium..  These  represent  the  primordial  follicles  (Fig.  6-4). 
Practically  the  same  process  has  been  observedm  human  beings  by  all 


60  OBSTETKICS 

embryologists.    For  full  information  concerning  it  the  student  is  referred 
to  the  works  of  JSTagel,  Wendeler,  and  Clark. 

The  ovary,  therefore,  in  its  earliest  stages,  consists  of  two  layers,  a 
single  layer  of  germinal  epithelium  covering  an  underlying  connective 
tissue  (Fig.  65).    In  human  beings  the  formation  of  primordial  ova  ceases 


^^-^~ 

-■V    -     . 

~^~~  |^ 

J^-:'~rS.y'>:--^^'-'H''  .-.v.. '•'■'■ '•'*£•:•,. 

1       .    ~     *       ^   .  .:\ 

^%yy'  '■' 

^c: — 

^.._^-- 

,--. :__ 

V.  Yi.--.iv'- 

i    SI 

1 

Fig.  66.— Ovary  of  New-born  Girl.     X  22. 

at  birth,  but  in  some  of  the  lower  animals,  especially  in  the  bat,  the 
process  may  continue  throughout  life. 

At  birth  the  greater  part  of  the  ovary  consists  of  the  cortex,  which 
is  made  up  of  closely  packed  primordial  iollicles,  whicli  are  separated  from 
one  another  by  very  thin  bands  of  connective  tissue,  although  occasionally 
small  groups  of  follicles  may  be  in  direct  contact.  At  this  period  the 
surface  of  the  ovary  is  covered  by  a  single  layer  of  cuboidal  epjthglinm 
which  shows  no  signs  of  proliferation  (Figs.  66  and  67). 

All  authorities  agree  that  the  primordial  ova  are  derived  from  the  ger- 
minal  epithelium,  but  there  is  still  considerable  discussion  as  to  the  origin" 
of  the  epithelium  surrounding  them.  According  to  Waldeyer  and  the 
majority  of  other  observers,  the  follicular  ppitlirlinmAs  derived  from  the 
cells  of  the  germinal  epithelium,  which  have  not  been  converted  into 
primordial  ovaT  Kollicker,  on  the"" other  hand,  believed  that  it  originated 
from  the  epithelium  of  the  Wolffian  bodies,  and  that  the  medullary  cords 
in  the  adult  ovary  represented  portions  of  the  Wolffian  body  which  were  not 
utilized  in  this  way.  Foulis,  in  1878,  stated  that  the  so-called  follicular 
epithelium,  was  derived  from  the  connective  tissue  of  the  ovary,  and  the 
recent  studies  of  Wendeler  and  Clark  tend  to  confirm  this  view.  Clark 
bases  his  conclusions  upon  his  observation  that  the  cells  surrounding  the 
primordial  follicles  are  spindle-shaped  and  differ  but  little  in  appearance 
from  the  adjacent  stroma  cells;  and  more  especially  upon  the  fact  that  in 


THE  OVARIES  61 

the  earlier  stages  of  the  ovary  many  of  the  primordial  ova  are  no1  sur- 
rounded by  epithelium  at  all.  Inn  arc  in  direct  contacl  with  the  surround- 
ing connective  tissue. 

Waldeyer's  view,  however,  has  obtained  almosl   universal  acceptai 
nor  would  it  seem  advisable  thai  Foulis's  theory  should  be  adopted  until 
more  convincing  evidence  has  been  <i< !< Iu<-i< I  in  support  of  it,  as  its  accept- 
ance would  necessitate  the  recasting  of  all  our  ideas  concerning  the  pathol- 
ogy of  the  ovary. 

In  rare  instances  the  surface  epithelium  of  the  ovary  may  be  ciliated, 
and  now  and  again,  as  has  been  pointed  out  by  Von   Velits  and  myself, 
the  follicular  epithelium  may  likewise  be  found  to  possess  cilia.     These 
observations,  in  spite  of  their  rarity,  speak  strongly  against  the  connective-   ) 
tissue  origin  of  the  follicular  cells. 

Microscopic  Structure  of  Ovary. — From  the  first  stages  of  its  develop- 
ment until  after  the  menopause  the  ovary  is  undergoing  constant  change. 
According  to  Waldeyer,  each  ovary  at  birth  contains  at  least  100.000  pri- 
mordial  ova.  the  majority  of  which  disappear  before  the  age  of  pubert  v; 
so  that  at  that  time  only  30.000  to  40.000  remain.  The  changes  concerned 
in  their  disappearance  will  be  considered  more  fully  when  we  consider  the 
corpus  luteuni. 


^    ^   <rsb 


Fig.  i37. — Ovary  at  Birth,  showing  Primordial  Follicles.     X  300. 

Before  taking  up  the  consideration  of  the  evolution  of  the  mature 
follicle,  it  may  be  well  to  mention  certain  historical  points  in  connection 
with  it.  The  Graafian  follicle  was  first  described  in  167-2  by  De  Graaf,  a 
physician  of  Delft,  who  not  only  observed  the  vesicles,  but  demonstrated 


62 


OBSTETRICS 


mm 


T 


the  presence  of  ova  in  the  tubes  of  rabbits.  The  human  ovum  was  first 
recognised  by  Von  Baer  in  1827,  its  nucleus  or  germinal  vesicle  by 
Purkyne  in  1830,  and  its  nucleolus  or  germinal  spot  a  few  years  later 
by  Wagner. 

In  the  young  child  the  greater  portion  of  the  ovary  is  composed  of  the 
cortex,  which  is  filled  with  large  numbers  of  closely  packed  primordial 

follicles,    those    nearest    the 


central  portion  of  the  ovary 
showing  the  most  advanced 
stages  of  development.  As 
was  mentioned  above,  the 
majority  are  destroyed  be- 
fore the  time  of  puberty. 

In  young  women  the  cor- 
tex contains  large  numbers  of 
primordial  follicles  separated 
by  thicker  or  thinner  bands 
of  connective  tissue,  which  is 
made  up  of  cells  with  spin- 
dle-shaped or  oval  nuclei. 
Each  primordial  follicle  con- 
sists of  an  ovum  and  its  surrounding  epithelium.  The  ovum  is  a  sin- 
gle cell,  more  or  less  round  in  shape,  with  a  clear  protoplasm  ana 
a  tolerably  large  nucleus  occupying  its  central  portion.  The  nucleus 
presents  a  marked  network,  and  at  one  point  a  well-defined  nucleolus 
and  numerous  accessory  nucleoli,  which  are  formed  at  the  intersec- 
tions  of  the   nuclear   thread-work. 


i  m 

if; 


Fig.  68. — Ovary  of  Young  Woman,  showing  Primor- 
dial Follicles  on  Left  Side  and  Follicle  just 
beginning  to  develop  on  Eight.     X  210. 


)l      According  to  jNTagel, 
remains  constant  in  size  from  birth 
until  the  transformation  of  the  pri- 


,  4,1 »       s* 


7*W¥~ 


2  \Vn,k.v«^, 


\*j  rum  iE#i&&*y*w\ 


Si 


K*  fi 


f*\ 


'ik 


%m 


n 


■&y*i&$"? 


.  :'■£#  Y* 


Fig.  69. — Developing  Follicle.     X  210. 


Fig.  70. — DEVELopiijg_£aLiicLE. 


mordial  into  the  typical  Graafian  follicle,  no  matter  at  what  period  of  life 
this  change  may  occur.  The  ova-measure  from  48  to  69  microns,  and  their 
nuclei  from  29  to  32  microns  in  diameter.     The  primordial  ovum  is  sur- 


THE  OVARIES  63 

rounded  by  a  single  layer  of  small  spindle-shaped,  epithelial  cells,  which 
are  somewhat  sharply  differentiated  from  the  still  smaller  spindle-shaped 
cells  of  the  surrounding  stroma  (Fig.  68). 

Occasionally  a  primordial  ovum  may  contain  two  nuclei  or  germinal 
vesicles,  as  has  been  shown  \)y  Nagel,  Klein,  yon  Franqu6,  and  others. 
Again,  occasionally  two  and  sometimes  three  distinct  ova  may  be  found 

in  a  single  primordial  follicle,  and  il  is  from  such  structure,-  that  mul- 
tiple pregnancies  not   infrequently  develop. 

When,  under  the  influence  of  factors  with  which  we  are  as  yel  unac- 
quainted, the  primordial  follicle  begins  to  develop,  we  notice  in  the  first 

T.  ex.  Tint  D.  M.d 


V«  V;*»%|^/&  >li^a5  fit  I  A  f. 


Fig.  71. — Nearly  Mature  Follicle.     X  210. 
D.,  discus  prpligerus  ;  31. G.,  membrana  granulosa;  T.ex.,  tunica  externa;  T.ini.,  tunica  interna. 

place  that  its  epithelium  becomes  converted  into  a  single  layer  of  euboidal 
cells  (Fig.  68).  JNuclear  tigures  soon  make  their  appearance,  and  the  cells 
begin  to  proliferate  rapidly,  so  that  in  a  very  short  time  the  ovum  becomes 
surrounded  by  a  number  of  layers  of  epithelial  cells.  Certain  of  these  cells 
undergo  degeneration,  and  vacuolated  areas  are  not  infrequently  observed 
between  them.  This  process  continues  until. a  considerable  portion  of  the 
follicle  is  filled  with  fluid,  which  is  formed  partly  by  the  degeneration  of 
the  follicular  cells  and  partly  by  transudation  from  surrounding  vessels. 
Coincident  with  the   development   of   the   fluid,   the   so-called   liquor 


64  OBSTETRICS 

folliculi,  the  ovum  becomes  pushed  to  one  side  of  the  follicle,  where  it  is 
surrounded  by  a  mass  of  cells — the  discus  proliaerus  or  cumulus  ooplwrus — 
while  the  rest  of  the  epithelium  is  arranged  in  a  number  of  layers  around  the 
interior  of  the  follicle,  and  is  known  as  the  membrana  granulosa  (Fig.  71). 

While  these  changes  are  taking  place,  the  ovum  itseirtj^^jmes  larger, 
yolk  granules  or  deutoplasm  are  deposited  in  its  protoplasm,  anclNi^thin, 
transparent  structure — the  W/W7/»g  mpmhmnp — appears  about  its  periphery. 
At  the  same  time,  the  stroma  immediately  surrounding  the  growing  fol- 
licle becomes  vascular,  and  its  cells  show  marked  evidences  of  prolifera- 
tion.  The  membrana  granulosa  is  separated  from  the  stroma  by  a  thin 
basement  membrane  consisting  of  a  single  layer  of  flattened,  spindle- 
sliap_ed,  connective-tissue  cells.  Just  between  the  basement  membrane 
and  the  outermost  layer  of  the  membrana  granulosa  there  not  infrequently 
appears  a  thin,  transparent  layer,  which  was  first  described  by  Grohe  and 
Slavjansky.  This,  no  less  than  the  vitelline  membrane,  is  a  species  of  exu- 
date from  the  granulosa  cells. 

Mature  Graafian  Follicle. — From  birth  until  the  cessation  'of  sexual 
life,  Graafian  follicles  are  constantly  being  developed.  Before  the  age  of 
puberty  they  are  found  only  in  the  deeper  portions  of  the  cortex,  and 
do  not  reach  the  surface  of  the  ovary;  later,  however,  they  develop  in  the 
superficial  portions  of  the  cortex  and  make  their  way  to  the  surface,  where 
they  appear  as  transparent  vesicles,  varying  from  2  or  3  to  10  or  15  milli- 
metres in  diameter.  As  the  follicle  approaches  the  surface  of  the  ovary  its 
walls  become  thinner  and  more  abundantly  supplied  with  vessels,  except 
in  its  most  prominent  projecting  portion,  which  appears  almost  Ifiooolless 
and  is  designated  asj-bp  stif/ma.  the  spot  where  rupture  is  to  occur. 

The  mature  Graafian  follicle  consists  of  a  connective-tissue  covering 
— the  theca  folliculi;  an  epithelial  lining — the  membrana  granulosa;  the 
ovum,  and  the  liquor  folliculi.  The  theca  folliculi  is  readily  divided  into 
two  layers:  an  outer,  the  tunica  externa,  and  an  inner,  the  Junica  interna. 
The  tunica  externa  consists  of  the  ordinary  ovarian  stroma,  which  is  ar- 
ranged concentrically  about  the  follicle,  while  the  connective-tissue  cells 
of  the  tunica  interna  have  undergone  marked  changes. 

Almost  as  soon  as  the  primordial  follicle  shows  signs  of  development, 
nuclear  figures  appear  in  the  stroma  immediately  surrounding  it,  and  a 
considerable  multiplication  of  cells  occurs.  These  become  considerably 
larger  than  the  surrounding  connective-tissue  cells,  and  as  the  follicle  in- 
creases in  size  assume  a  granular  appearance,  which  is  due  to  the  presence 
of  a  yellowish  pigment.  These  cells  are  designated  as  lutein  cells  and,  as 
will  be  seen  later,  play  an  important  part  in  the  formation  oftne  corpus 
luteum.  In  most  hardened  specimens  the  colouring  matter  has  been  dis- 
solved out,  and  the  cells  appear  not  unlike  those  of  the  suprarenal  cap- 
sules (see  T.I.,  Fig.  72).  At  the  same  time  there  is  a  marked  increase  in  the 
vascularity  of  the  theca,  and  numerous  lymphatic  spaces  make  their  appear- 
ance. 

The  epithelial  lining  of  the  follicle,  or  mem  bra  n  aj/ra  n  u  hsa ,  consists  of 
a  number  of  layers  of  small  polygonal  or  cuboidal  cells,  with  round,  darkly 
staining  nuclei,  which  are  arranged  in  fewer  layers  the  larger  ffie  follicle. 


'HE  OVARIES 


65 


At  one  poinl  the  membrana  granulosa  is  much  thicker  than  elsewhere,  and 
forms  a  more  or  Less  pyramidal  mound  in  which  the  ovum  is  included. 
This  is  the  discus  proligerus  or  oophorus,  and  is  usually  situated  at  the  por- 
tion of  the  fTTTTuU'  farthest  removed  Trmn  the  surface  of  the  ovary  (see 
Fig.  ~i  1 ).  The  follicle  is  filled  with  a  clear,. albuminous  fluid,  the  Liquor  fol- 
lieuli.  which  is  partly  the  product  of  the  degenerated  follicular  epithelium 
and  partly  a  transudate  from  surrounding  vessels.  As  the  follicle  approaches 


M.G. 


Fig.  72. — Section  through  Wall  of  Mature  Follicle  (highly  magnified). 
M.G.,  membrana  granulosa  ;   T.I..  tunica  interna  ;  T.E.,  tunica  externa. 

its  highest  development,  marked  alterations  appear  in  the  follicular  epi- 
thelium, which  by  appropriate  methods  can  be  demonstrated  as  due  to 
fatty  degenerative  changes. 

The  ovum  becomes  much  larger  as  it  approaches  maturity,  and,  ac- 
cording to  Xagel,  measures  from  150  to  250  microns  (-i  millimetre)  in 
diameter,  as  compared  with  48  to  69  microns  in  its  primordial  condition. 

If  the  mature  ovum  be  examined  in  the  liquor  folliculi  or  in  normal 
salt  solution,  the  following  structures,  according  to  Xagel,  may  be  distin- 
guished in  and  about  it:  (a)  a  corona  radiata;  (b)  a  zona  pellucida;  (c)  a 
perivitelline  space;  (d)  a  small,  clear  zone  of  protoplasm;  (e)  a  broad,  finely 
granulated  zone  of  protoplasm;  (/)  a  central,  deutoplasmic  zone:  and  (g) 
the  germinal  vesicle  with  its  germinal  spot. 

The  corona  raMata  consists  of  a  number  of  layers  of  follicular  epithe- 
lium which  adhere  to  the  ovum,  and  was  so  designated  by  Bischoff,  by 
whom  it  was  first  described.  Inside  of  the  corona  radiata  comes  a  trans- 
parent zone — the  zona,  pellucida — which  is  a  product  of  the  granulosa  cells, 
and  does  not  belong  to  the  ovum  itself.  Separating  the  ovum  from  the  zona 
pellucida  is  a  clear,  narrow  space,  the  perivitelline  space,  within  which  the 


66  OBSTETRICS 

ovum  is  freely  movable,  so  that  no  matter  what  position  it  may  assume  its 
germinal  vesicle  will  always  point  upward.  Inside  of  the  perivitelline  space 
is  the  ovum  proper,  which  differs  markedly  from  the  primordial  ovum, 
not  only  by  its  increased  size,  but  more  especially  by  the  presence  of  a 
yolk  or  deutoplasm  which  fills  the  greater  part  of  its  interior.  The 
deutoplasm  occupies  the  central  portion  of  the  ovum,  and  is  made  up  of 
large  numbers  of  irregularly  shaped,  highly  refractive  granules.  As  it 
develops  it  pushes  the  germinal  vesicle  to  one  side,  so  that  the  latter  always 
assumes  an  eccentric  position  in  the  ovum. 

Outside  of  the  deutoplasm  comes  a  narrow  zone  of  finely  granular 
protoplasm,  which  owes  its  peculiar  appearance  to  the  presence  of  very 
small  yolk-granules;  external  to  this,  again,  is  a  still  narrower  zone  of 
clear  protoplasm. 

The  germinal  vesicle  presents  a  distinct  nuclear  network,  the  inter- 
sections of  which  appear  as  very  darkly  staining  points.  The  nucleolus  or 
germinal  spot  is  much  larger  than  in  the  primordial  ovum,  and  according 
to  Auerbach  presents  typical  amoeboid  movements. 

A  follicle  presenting  the  above  characteristics  is  generally  described  as 
mature,  but  is  not  capable  of  fertilization  and  further  development  until 
its  nucleus  has  undergone  certain  changes  which  are  manifested  by  the 
formation  and  casting  off  of  the  polar  bodies. 

Graafian  follicles,  as  we  have  already  pointed  out,  develop  throughout 
childhood,  and  occasionally  attain  a  considerable  size;  but  they  rarely 
rupture  at  this  time  on  account  of  their  position  in  the  depths  of  the 
ovary  and  the  intervention  of  a  thick  layer  of  cortex  between  them  and  the 
surface.  In  adults,  on  the  other  hand,  the  developing  follicle  makes  its 
way  to  the  surface,  and  when  it  has  attained  its  highest  development  rup- 
tures and  extrudes  its  ovum  into  the  peritoneal  cavity  or  the  tube,  where 
it  may  be  fertilized. 

Formerly  it  was  believed  that  rupture  of  the  follicle  was  brought  about 
by  the  increased  tension  resulting  from  the  rapid  formation  of  the  liquor 
folliculi,  which,  according  to  jSTagel,  was  markedly  accentuated  by  the 
pressure  exerted  by  the  lutein  cells  developing  about  its  periphery.  Clark, 
however,  has  lately  shown  that  rupture  of  tbp  follir-lp.  is  a  complex  process, 
and  is _ due  primarily  to  circulatory  changes.  As  .the  period  of  ovulation 
approaches,  the  ovary  becomes  engorged  with  blood,  and  the  intra-ovarian 
tehsion~B^ing  markedly  increased,  the  growing  ovum  is  forced  to  the  sur- 
face; at  the  same  time  the  circulation  in  the  most  distended  portion  of  the 
wall  of  the  follicle  is  interfered  with,  whence  results  necrosis  at  the  point 
designated  as  the  stigma,  which  eventually  gives  way. 

Corpus  Luteum. — The  corpus  luteum  is  a  structure  which  is  formed  at 
[the  site  of  a  ruptured  follicle.  Its  function  would  appear  to  be  the  preser- 
vation of  the  cortical  circulation  of  the  ovary,  by  preventing  an  excessive 
formation  of  scar  tissue. 

When  the  mature  follicle  ruptures,  the  ovum,  liquor  folliculi,  and  a 
considerable  portion  of  the  degenerated  membrana  granulosa  make  their 
escape,  and  the  walls  of  the  empty  follicle  collapse.  In  a  short  time,  how- 
ever, its  cavity  becomes  filled  with  blood,  which  is  derived  partly  from 


THE  OVARIES  67 

the  vessels  atlhe  point  of  rapture,  bul  principally  from  those  of  (lie  tunica 
interna  of  the  theca. 

The  corpus  liiteinn,  therefore,  in  its  earliesl  stages  is  simply  a  rup- 
tured rolliele  lilh'tj  with  blood,  outside  of  which  is  a  narrow  yellow  rmg 
formed  by  the  lutein  cells  of  the  (Tuva,  which,  however,  prolileratc  rnphUy 
and  imade  the  blood-lilleil  tolliele,  forming  a  festooned  layer  about  its 
eeutral  blood-clot  (Fi.U'.  1->).  TTi is  layer  is  yellowish  in  colour,  whence 
the  term  "  corpus  IuIclilluJ'     As  the  structure  becomes  older,  the  yellow 


-I-  F. 


CF. 


Fig.  73. — Portion  of  Ovary,  showing  a  Corpus  Lvteum  of  Pregnancy,  with  Cystic  Centre. 

X4. 
B.C.,  blood-clot ;  C.F.,  corpus  fibrosum;  F.,  Graafian  follicles  ;  L.C.,  lutein  cells. 

ring  becomes  thicker  and  thicker,  until  at  last  it  almost  entirely  fills  the 
interior  of  the  follicle,  the  central  blood-clot  remaining  being  now  quite 
small. 

At  its  greatest  development  the  corpus  luteum  is  alwaysjargej  than 
the  original  follicle,  and  not  infrequently  occupies  a  considerable  portion 
of  the  ovary,  sometimes  as  much  as  one-third  of  the  entire  organ. 

Microscopic  sections  through  a  well-developed  example  show  that  its 
centre  is  occupied  by  a  compressed  blood-clot,  immediately  outside  of  which 
is  a  thin  layer  of  newly  formed  connective  tissue.  The  greater  part  of 
the  structure,  however,  is  occupied  by  the  festooned  yellow  ring,  which 
is  made  up  of  large  polygonal  epithelioid  cells,  with  small,  round,  somewhat 
fajntly  staining  nuclei.  These  are  the  lutein  cells,  whose  protoplasm  has 
taken  on  a  granular  appearance  due  to  the  presence  of  a  peculiar  yellow 
pigment  which  is  soluble  in  chloroform,  alcohol,  and  ether.     The  layer  of 


68  OBSTETRICS 

lutein  cells  is  traversed  by  numerous  radiate,  tolerably  thick,  connective- 
tissue  partitions,  to  which  it  owes  its  festooned  appearance.  They  are 
richly  supplied  with  blood-vessels  and  lymphatics  (Fig.  74). 

As  the  cavity  of  the  follicle  is  encroached  upon  by  the  growing  lutein 
cells,  the  blood-clot  becomes^  more  and  more  compressed,  and  vascular 
loops  extend  into  it  and  soon  cause  its  organization.  At  the  same  time,  the 
blood  pigment  is  removed  by  leucocytes,  which  can  be  found  in  the  sur- 
rounding tissue  Willi  Lheir  bodies  filled  with  particles  of  it.  Occasionally 
haemorrhage  does  not  take  place  into  the  ruptured  follicle,  and  a  corpus 


■-■-'. 


«.,:-fc 


FlG.    74.— SECTION   THROUGH    YELLOW   LaYEB    OF    CoEPL'S   LuTEOI,    SHOWING    LUTEIN    CELLS. 

luteum  is  formed  without  a  central  blood-clot.  This  is  the  exception  in 
human  beings,  but  the  rule  in  many  of  the  lower  animals,  as  in  the  rabbit 
and  mouse. 

After  the  cavity  of  fhp  fn11ir-\p  has  become  obliterated  by  the  ingrowth 
of  the  lutein  cells  and  connective  tissue,  de-genera f ^'p  r/|1  ^ v  °'p-^  soon  make 
their  appearance  in  the  former,  some  of  which  undergo  hvalin  and  others 
fatty  degeneration.  In  young  women,  in  whom  the  circulation  is  active, 
the  degenerated  lutein  cells  are  rapidly  absorbed,  so  that  in  a  short  time  the 
corpus  luteum  becomes  replaced  by  newly  formed  connective  tissue  which 
corresponds  closely  in  appearance  to  the  surrounding  ovarian  stroma.  But 
in  more  advanced  life,  when  the  ovarian  circulation  has  become  impaired, 
absorption  goes  on  less  rapidly;  and  not  infrequently  the  degeneration 
extends  to  the  intervening  connective  tissue  and  blood-vessels  until  the 
entire  structure  is  converted  into  an  almost  homogeneous  mass  of  hvalin 
in  which  only  a  few  connective-tissue  cells  and  degenerated  blood-vessels 
can  be  seen  (Fig.  vo).  These  structures — the  so-called  corpora  fibrosa  or 
aWicantia — present  on  fresh  section  a  dull  white  appearance,  somewhat 


THE  OVARIES  G'J 

suggestive  of  old  scar  tissue.  They  are,  however,  ■jnnlually  invaded  In-  the 
surrounding  stroma,  and  become  broken  up  into  smaller  and  smaller  hya- 
lin  masses,  which  are  eventually  absorbed,  the  site  of  the  original   fol- 


. 


licle  being  indicated  only  by  an  area  of  slightly  thickened  connective  tissue. 
When  the  circulation  is  very  defective,  absorption  takes  place  much  more 
slowly,  so  that  it  is  not  uncommon  to  find  the  ovaries  of  women  near  the 
menopause  almost  filled  by  corpora  fibrosa  of  varying  size.  Xot  infrequently 
the  small  hyalin  bodies  resulting  from  the  breaking  up  of  these  structures 
assume  peculiar  and  bizarre  forms,  and  very  often  present  a  curved  and 
twisted  appearance  suggest- 
ive of  a  degenerated  arl 
(Fig.  T6).  Similar  struc- 
tures are  sometimes 
after  the  obliteration 
non-ruptured  follicles. 

Practically  all  authori- 
ties are  agreed  as  to 
life-history   of   the    cor] 
luteum,  and  the  onl}r  point 
which  still  remains  uns 
t lcil   deals 
of    tlie    lutei 
earlier     ob 
ered  that  the  _. 

analogous  to  the  organiza-  FlG   7g._Later  Stage  of  Corpus  Fibeosum.    X75. 

tion  of  a  blood-clot  which 

was  followed  by  the  formation  of  cicatricial  tissue,  but  at  present  this  view 
possesses  only  an  historical  interest. 

The  majority  of  investigators  believe  that  the  lutein  cells  are  of  con- 
nective-tissue origin  and  represent  the  cells  of  the  theca  interna.     This 


70  OBSTETRICS 

view  was  first  advanced  by  von  Baer,  and  has  been  confirmed  by  the  work 
of  Kollicker,  His,  Beigel,  Benckiser,  Nagel,  Clark,  and  many  others.  A 
few  authors,  on  the  other  hand,  following  the  example  of  Bischoff,  consider 
that  they  originate  from  epithelial  cells  and  are  derived  from  those  of 
the  membrana  granulosa.  This  explanation  has  been  advocated  more  par- 
ticularly by  Sobotta,  and  has  lately  received  additional  support  from  the 
work  of  Kreis.  Full  details  of  the  discussion  are  contained  in  the  recent 
papers  of  Clark  and  Doering.  I  shall  content  myself  with  giving  the  evi- 
dence in  favour  of  the  former  view. 

The  connective-tissue  origin  of  the  lutein  cells  is  based  upon  two  facts: 
first,  the  cells  of  the  tunica  interna  of  the  theca  begin  to  undergo  marked 
changes  as  soon  as  the  follicle  commences  to  develop;  and  secondly,  the 
membrana  granulosa  presents  extensive  degenerative  changes,  and  is  usu- 
ally cast  off  in  great  part  at  the  time  of  rupture. 

In  the  early  stages  of  follicular  development,  the  cells  of  the  theca 
interna  become  larger  and  assume  an  epithelioid  appearance.  Nuclear  fig- 
ures soon  appear  and  rapid  proliferation  ensues.  At  the  same  time  their 
protoplasm  becomes  more  granular,  and  pigment  is  deposited  within  them, 
so  that  they  closely  resemble  the  lutein  cells.  That  they  first  appear  in 
the  theca  would  argue  against  their  derivation  from  the  membrana  granu- 
losa, but  even  more  so  the  fact  that  they  are  separated  from  it  by  a  definite 
barrier  of  unchanged  connective  tissue,  the  upper  layer  of  which  forms 
the  basement  membrane  of  the  follicle  (see  Figs.  72  to  74). 

The  mature  follicle,  then,  is  surrounded  by  actively  proliferating 
lutein  cells,  while  its  membrana  granulosa  shows  signs  of  fatty  degenera- 
tion. In  many  instances,  before  rupture,  a  narrow  yellow  ring  may  be 
found  surrounding  the  periphery  of  the  follicle,  from  which  it  is  separated 
by  a  thin  layer  of  connective  tissue.  As  soon  as  the  follicle  ruptures  the 
lutein  cells  proliferate  more  rapidly,  and  with  the  vessels  included  between 
them,  speedily  invade  the  follicular  cavity. 

Observations  based  upon  the  study  of  several  hundred  human  corpora 
lutea  have  convinced  me  that  the  connective-tissue  origin  of  the  lutein 
cells  is  established  beyond  all  reasonable  doubt.  Strong  support  in  favour 
of  this  view  is  also  to  be  obtained  from  the  changes  which  are  observed  in 
follicles  which  develop  in  the  deeper  portions  of  the  ovary,  and  degenerate 
without  rupture.  This  process  has  been  studied  by  a  number  of  observers, 
notably  Slavjansky,  Schottlander,  Clark,  and  others,  and  is  usually  desig- 
nated as  follicu  lara  tresia.  Under  such  circumstances,  precisely  the  same 
changes  are  observed  as  in  the  formation  of  the  corpus  luteum,  except 
that  hemorrhage  is  absent  and  that  the  process  is  less  marked.  In  many 
instances  the  entire  membrana  granulosa  is  separated  from  the  walls  of  the 
follicle  and  lies  free  in  its  cavity,  presenting  marked  signs  of  fatty  de- 
generation, while  the  cells  of  the  theca  are  actively  proliferating  and  are 
being  converted  into  lutein-like  cells. 

The  function  of  the  corpora  lutea  is  to  bring  about  the  obliteration  of 
the  spaces  left  by  the  ruptured  follicles  without  the  formation  of  cica- 
tricial tissue;  for  if  they  healed  by  the  latter  process  it  is  evident  that  in 
a  very  short  time  the  entire  ovary  would  be  converted  into  a  mass  con- 


THE  OVARIES  71 

sisting  of  nothing  bu1  scar  tissue,  the  very  nature  of  which  would  effectu- 
ally prevent   Eurther  ovulation.     It  has  been  estimated  by  ('lark  thai   if 
each  follicle  bealed  in  this  manner,  and  if  ovulation  could  continue  under 
such  conditions,  a  fibroma  would  eventually  be  produced  5,000  tim< 
large  as  the  original  ovary. 

It  is  usual  to  distinguish  between  true  and  [ulsr  corpora  lutea — namely, 
those  following  impregnation  andjncnstruai  ion  respectively.  This  distinc- 
tion is  based  entirely  upon  their  relative  size,  and  not  upon  any  inherent 
anatomical  difference,  as  they  both  present  exactly  the  same  structure,  the 
larger  size. of  the  so-called  true  corpus  luteum  being  simply  due  to  the  in- 
ereased  vascular  supply  incidenMo  pregnancy. 

Xot  infrequently  the  corpus  luteum  of  pregnancy  contains  in  its  centre 
a  small  cyst  filled  with  clear  fluid,  the  walls  of  which  are  composed  of  / 
connective  tissue,  outside  of  which  are  the  typical  lutein  cells.    Such  cysts/ 
are  due  to  the  liquefaction  of  the  central  blood-clot  (see  Fig.  73). 

In  rare  instances  the  corpus  luteum,  instead  of  disappearing  in  the 
manner  just  described,  may  be  the  starting-point  of  cystic  formations,  to 
which  attention  was  first  directed  by  .Kokitansky,  and  with  which  every 
gynaecologist  is  now  familiar. 

The  corpus  luteum  was  first  described  by  De  Graaf  as  a  conglomerate 
glandular  body,  and  was  considered  by  him  and  all  earlier  authorities  as 
positive  evidence  of  previous  childbearing.  Moreover,  it  was  generally 
believed  that  the  number  of  children  which  a  woman  had  borne  could 
readily  be  estimated  by  counting  the  number  of  corpora  lutea  in  her 
ovaries.  This  yiew  was  held  for  many  years,  and  was  so  firmly  established, 
even  at  the  end  of  the  eighteenth  century,  that  such  eminent  authorities  as 
Abernethy,  Sir  Astley  Cooper,  and  Denman,  had  no  hesitancy  in  swearing 
in  a  medico-legal  case  that  a  woman  had  been  pregnant  because  a  corpus 
luteum  was  found  in  one  ovary.  Even  after  the  more  frequent  perform- 
ance of  autopsies,  and  the  closer  attention  directed  to  the  condition  of  the 
oyaries  had  led  to  the  abandonment  of  this  yiew.  it  was  for  a  time  believed 
that  the  presence  of  corpora  lutea  indicated  that  the  individual  had  in- 
dulged in  sexual  relations,  or  had  at  least  been  under  marked  sexual  ex- 
citement. Finally,  as  a  result  of  the  work  of  Bischoff.  Eaciborski.  Xegrier, 
and  Pouchet  (1840-'47),  it  was  definitely  established  that  the  corpus  lu- 
teum was  not  necessarily  a  sign  of  pregnancy,  but  occurred  after  each 
menstrual  period  in  virginal  as  well  as  married  women.  For  fuller  infor- 
mation an  this  point  the  works  of  Montgomery  and  Dalton  may  be  con- 
sulted. 

LITERATURE 
Auerbach.     Quoted  by  Nagel. 

Vox  Baer.     De  ovi  mammalium  et  hominis  genesi.     Leipzig.  1827. 
Beigel.     Zur  Xaturgeschiehte  des  Corpus  luteum.     Arehiv  f.  Gyn..  xiii.  100-122.  1878. 
Bexckiser.     Zur  Entwickelungsgeschiehte  des  Corpus  luteum.     Arehiv  f.  Gyn..  xxiii. 

350-367.  1884. 
Bestiox  de  Camboulas.     Le  sue  ovarian.     Paris.  1898. 
BisrHOFF.     Entwiekelunsrsffeschiehte  der  Saugethiere  und  des  Mensehen.  1842. 

Beweis  der  von  der  Begattung   unabhangigen  periodisehen    Reifung  und   Loslosung 

der  Eier  als  der  ersten  Bedingung  ihrer  Fortpflanzung.  etc.     Giessen.  1844 


72  OBSTETRICS 

Clark.     The  Origin,  Growth,  and  Fate  of  the  Corpus  Luteum.     Johns  Hopkins  Hospital 

Reports,  vii,  181-220,  1898. 
The  Origin,  Development  and  Regeneration  of  the  Blood-vessels  of  the  Ovary.     Con- 
tributions to  the  Science  of  Medicine,  by  pupils  of  William  H.  Welch,  1900,  593-676. 
Cornil.     Note  sur  l'histologie  des  corps  jaunes  de  la  femme.    Annales  de  Gyn.  et  d'Obst., 

lii,  373-381,  1899. 
Dalton.     On  the  Corpus  Luteum  of  Menstruation  and  Pregnancy.     Philadelphia,  1851. 
Doering.     Beitrag  zur  Streitfrage  iiber  die  Bildung  des  Corpus  luteum.     D.  I.,  Konigs- 

berg,  1898. 
Engstrom.     Ueberzahlige  Ovarien.     Mittheil.  der  gyn.  Klinik  des  Prof.  Engstrom,  i,  55, 

1897. 
Parre.     Uterus  and  its  Appendages.     Todd's  Cyclopaedia  of  Anatomy  and  Physiology, 

Parts  XLIX  and  L,  1858. 
Foulis.     The  Development  of  the  Ova,  etc.,  with  Special  Reference  to  the  Origin  and 

Development  of  the  Follicular  Epithelial  Cells.     Jour,  of  Anat.  and  Physiol.,  xiii. 
von  Franque.      Beschreibung  einiger  seltenen  Eierstockspraparate.     Zeitschr.  f.  Geb.  u. 

Gyn.,  xxxix,  326-346,  1898. 
Gawronsky.     See  Anatomy  of  Uterus. 
de  Graaf,  Regnerus.     De  mulierum  organis  generationi  inservientibus  tractatus  novus, 

etc.     Lugd.,  1672. 
Grigorieff.      Schwangerschaft  bei  der  Transplantation  der  Eierstocke.      Centralbl.  f. 

Gyn.,  1897,  663. 
Grohe.     Ueber  den  Bau  und  das  Wachstum  des  menschlichen  Eierstockes,  etc.    Virchow's 

Archiv,  xxvi,  1863. 
von  Herff.      Ueber  den  feineren  Verlauf   der  Nerven   im    Eierstocke   des   Menschens. 

Zeitschr.  f.  Geb.  u.  Gyn.,  xxiv,  289-308,  1892. 
His.     Beobachtungen  iiber  den  Bau  des  Saugethiere-Eierstockes.    Archiv  f.  mikros.  Anat., 

i,  1865. 
Klein.     Ueber  mehreiige  Graaf'sche  Follikel  beim  Menschen.    Miinchener  med.  Abhand- 

lungen,  IV.  Reihe,  Heft  4,  1893. 
Knauer.     Die  Ovarientransplantation.     Archiv  f.  Gyn.,  lx,  322-376,  1900. 
Kollicker.     Entwickelungsgeschichte  des  Menschen  und  der  hoheren  Thiere.     II.  Aufl., 

Leipzig,  1879. 
Kreis.     Die  Entwickelung  und  Riickbildung  des  Corpus  luteum  spurium  beim  Menschen. 

Archiv  f.  Gyn.,  lviii,  411-427,  1899. 
Mandl.    Ueber  Anordnung  und  Endigungsweise  der  Nerven  im  Ovarium.    Arch.  f.  Gyn., 

xlviii,  276-292,  1895. 
Montgomery.     An  Exposition   of    the  Signs   and   Symptoms  of   Pregnancy.     2d  ed., 

London,  1863,  419-489. 
Morris.     The  Ovarian  Graft.    New  York  Medical  Journal,  October,  1895. 
Nagel.     Das  menschliche  Ei.     Arch.  f.  mikros.  Anat.,  xxxi. 

Die  weiblichen  Geschlechtsorgane.     Jena,  1896. 
Negrier.     Recherches  anatomiques  et  physiologiques  sur  les  ovaries  dans  l'espece  humaine. 

Paris,  1840. 
Pfluger.     Ueber  die  Eierstocke  der  Saugethiere  und  des  Menschen.     Leipzig,  1867. 
Pouchet.      Theorie  positive  de  l'ovulation  spontanee  et  de  la  fecondation,  etc.     Paris, 

1847. 
Purkyne.     Symbolae  ad  ovi  avium  historiam  ante  incubationem.     Lipsiae,  1830. 
Raciborski.     De  la  puberte  et  de  l'age  critique  chez  la  femme,  et  de  la  ponte  periodique 

chez  les  mammiferes.     Paris,  1844. 
Rokitansky.     Ueber  Abnormitaten  des  Corpus  luteum.     Allg.  Wiener  med.  Zeitung,  iv, 

Nr.  34,  35,  1859. 
Rouget.     Recherches  sur  les  organes  erectiles  de  la  femme,  etc.     Jour,  de  la  Physiol.,  i, 

1858. 


THE  OVARIES  7:! 

Schottlander.     Ueber  den  Graaf'schen   Follikel,  etc.     Archiv  r.  mikros.  Anat.,  scxxi, 

219-294. 
Slavjansky.    Zur  normalen  u.  path.  Histologic  der  Graaf'schen  Bl&scben  des  Menschen, 

Virchow's  Archiv,  li,  L870. 
Sobotta.     Ueber  die  Bildung  des  Corpus  luteuin  bei  der  .Man-.     Archiv  C.  mikros,  Anal., 

\l\ii.  1897. 
Thumin.     UeberzShlige  Eicrstocke.     Archiv  I*.  Gyn.,  Lvi,  342  354,  L898. 
Valentin.     Eandbuch  der  Entwickelungsgeschichte  des  Menschen,     Berlin,  L835. 
Vallet.    Nerfs  d'ovaire,  etc.    These  de  Paris,  L900. 
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EierstOcks.     Zeitschr.  !'.  Geb.  u.  Gyn.,  xvii,  232-278,  L889. 
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Beitrage  zur  Keuntniss  der  Lage  der  weiblichen  Beckenorgane.     Bonn,  L892. 
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790-804,  L899. 
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Krankheiten  des  Eierstocks  u.  Nebeneierstocks,  Leipzig.  L899,  16-105. 
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Gyn.,  li,  49-55,  1806. 


PHYSIOLOGY   A2STD    DEVELOPMENT    OF    THE    OVUM 

CHAPTER  III 

MENSTRUATION  AND    OVULATION— MIGRATION   OF   TEE   OVUM 
AND  PLACE   OF  MEETING   OF  OVA  AND  SPERMATOZOA 

Menstruation. — By  menstruation  we  understand  a  process  characterized 
by  a  discharge  of  blood  from  the  genitalia,  which  recurs  at  regular  .intervals, 
except  during  pregnancy  and  lactation,  from  the  time  of  puberty  until  the 
menopause.  Ordinarily  it  comes  on  every  four  weeks  and  lasts  from  three 
to  five  days,  though  there  are  marked  individual  variations  as  to  its  fre- 
quency and  duration. 

The  age  at  which  the  menses  are  established  varies  in  different  coun- 
tries, being  earlier  in  warm  and  later  in  cold  climates.  In  the  temperate 
zone,  the  first  menstruation  does  not  usually  occur  before  the  fourteenth 
or  fifteenth  year.  Not  a  few  instances  of  a  much  earlier  appearance  of  the 
function,  however,  are  to  be  found  in  the  literature,  and  are  usually  asso- 
ciated with  precocious  sexual  development.  One  of  the  most  notable 
cases  of  this  character  is  that  of  Anna  Mummenthaler,  who,  according  to 
Ilaller,  menstruated  regularly  from  her  second  year,  and  gave  birth  to 
a  full-term  child  at  the  age  of  nine. 

Not  infrequently  a  bloody  vaginal  discharge  is  observed  in  new-born 
infants,  which  ceases  after  a  few  days,  no  further  discharge  being  noted 
until  puberty.  To  describe  these  as  instances  of  precocious  menstruation, 
however,  would  be  incorrect. 

In  this  country  the  menopause  usually  occurs  about  the  forty-fifth 
year.  In  rare  instances,  however,  the  menstrual  flow  may  cease  as  early 
as  the  twenty-eighth  or  thirtieth  year,  while  not  very  infrequently  it  con- 
tinues until  well  into  the  fifties,  and  occasionally  until  even  a  later  period. 
Thus,  Kennedy  reports  the  case  of  a  woman  who  gave  birth  to  her  twenty- 
second  child  when  she  was  sixty-three  years  old,  after  which  she  still  con- 
tinued to  menstruate.  For  various  interesting  historical  and  ethnological 
points  concerning  menstruation,  the  reader  is  referred  to  the  works  of 
Ploss  and  Ottokar  Alt. 

The  menstrual  flow  is  derived  from  the  uterine  mucosa,  and  consists 
of  blood  mixed  with  mucus,  which,  under  ordinary  circumstances,  will  not 
coaguTaTe! 

Anatomical  Changes  in  Menstruation. — The  statements  concerning  the 
extent  of  the  changes  occurring  in  the  endometrium  during  menstruation 
are  very  contradictory.  Sir  John  Williams  believes  that  the  entire  mucosa 
74 


E, •'*','>  »?!•«.  •-•i",'  ■'''•"''""'■••',, 


G.  a. 


SECTION  THROUGH  ENDOMETRIUM  ON  THIRD   DAY   OE  MENSTRUATION. 

X  52. 

B,  blood;   B.  (?.,  gland  filled  with  blood;  Ep„  surface  epithelium;   G.,  hypertrophied  glands; 

S-  stroma. 


MENSTRUATION  7:. 

is  cast  off  at  each  menstrual  period,  while  Moericke  and  numerous  other 
observers  state  thai  there  is  little  or  no  destruction  of  tissue.  Between 
these  extremes,  we  find  a  number  of  authors  stating  thai  a  greater  or  lesser 
portion  undergoes  disintegration.  Generally  speaking,  the  older  author- 
ities held  thai  the  entire  mucosa,  or  at  leasl  a  considerable  pari  of  it,  was 
casl  off.  Their  adoption  of  this  view  is  probably  explained  by  the  fad 
that  their  conclusions  were  drawn  from  the  study  of  uteri  in  which  post- 
mortem changes  had  taken  place,  since  De  Sinety  \\a>  the  only  observer 
among  those  whose  work  was  based  upon  autopsy  specimens,  who  stated 
that  there  was  hut  little  destruction  of  tissue. 

In  18S--3  Moericke  expressed  the  opinion  that  menstruation  was  accom- 
panied by  little  or  no  destruction  of  tissue,  basing  his  statements  upon 
tlic  examination  of  45  specimens  of  the  menstruating  endometrium  which 
he  obtained  by  curettage.  His  views  were  soon  confirmed  by  other  ob- 
servers, anion-'  whom  may  be  mentioned.  De  Sinety,  Lohlein,  Westphalen, 
Strassmann,  Gebhard,  and  Findley.  Meerdevoort  and  Mandl  consider  that 
the  extent  to  which  the  tissue  is  destroyed  varies  within  wide  limits,  the 
being  almost  imperceptible  in  some  individuals  and  quite  marked  in  others: 
while  Kahlden  and  Christ  believe  that  the  destruction  is  always  consider- 
able. 

My  own  experience,  based  upon  the  examination  of  several  uteri  re- 
moved during  the  menstrual  period  and  numerous  specimens  obtained  by 
curettage,  is  such  that  I  have  no  hesitation  in  adopting  the  views  of 
Moericke  and  his  supporters. 

Plate  III,  which  represents  a  section  through  the  endometrium  of  a 
uterus  removed  on  the  third  day  of  menstruation,  shows  very  distinctly 
that  but  little  destruction  of  tissue  has  occurred.  The  entire  mucosa  is 
markedly  thickened,  and  its  superficial  portion  is  infiltratedwith  blood. 
The  surface  epithelium  is  intact,  but  in  places  it  lias  been  separated  from 
the  underlying  tissue  by  small  collections  of  blood — the  so-called  subepi- 
thelial haematomata  of  Gebhard.  The  uterine  glands  are  markedly  hypcr- 
trophied.  as  is  shown  by  their  twisted  and  corKscrew-hke^course :  this  hyper- 
trophy is  associated  with  a  considerable  increase  in  the  interglariilular  tis- 
sue, the  cells  of  wriich,  however,  do  not  appear  to  have  undergone  changes 
in  shape.  There  is  marked  engorgement  of  the  blood-vessels,  and  just  be- 
neath the  surface  epithelium  may  be  seen  capillaries  which  are  distended 
almost  to  the  point  of  bursting,  while  considerable  quantities  of  blood  have 
escaped  from  the  vessels  and  lie  free  in  the  tissues.  From  these  and  similar 
observations,  then,  it  would  seem  evident  that  menstruation  is  not  attended 
by  any  great  loss  of  tissue,  but  consists  essentially  in  marked  hypertrophy 
of_f|-|p  mucosa  pnor>ro-pmpr|t  of  its  superficial  vessels  and  the  consequent 
pscapp  nf  blnnd  partly  following  rupture,  but  in  great  measure  by  diape- 
desis. 

After  the.mpnstrnnl  flow  has  ceased,  a  certain  amount  of  defeneration 
takes  place  in  the  superficial  layers  of  the  mucosa,  which,  however,  is  soon 
repaired,  nuclear  figures  appearing  in  the  cell-  of  the  epithelium  and  inter- 
glandular  tissue,  which  begin  to  multiply  and  replace  the  degenerated 
cells,  so  that  regeneration  is  rapidly  effected. 


76  OBSTETRICS 

As  menstruation  occurs  every  twenty-eight  clays,  it  is  apparent  that  the 
endometrium  is  subjected  to  an  almost  continuous  change,  the  process 
being  described  by  Leopold  and  others  as  the  nienstrual  cycle.  This 
covers  a  period  of  sixteen  days,  five  of  which  are  needed  for  the  prelimi- 
nary swelling,  four^  for  the  menses  proper,  and  seven,  for  the  period  of 
regeneration,  so  that  the  endometrium  remains  quiescent  only  about  twelve 
days  in  each  month.  For  further  particulars  concerning  the  anatomical  de- 
tails observed  in  menstruation,  the  exhaustive  article  of  Gebhard  should  be 
consulted. 

Relation  between  Menstruation  and  Ovulation. — By  ovulation  we  un- 
derstand tlie.Tnptm-p^  of  a  mature  Graafian  follicle  and  the  extrusion  of  the 
ovum.  The  relation  between  menstruation  and  ovulation  has  given  rise  to 
a  great  deal  of  controversy,  and  while  many  interesting  facts  have  been 
added  to  our  information,  it  must  be  conceded  that  the  subject  is  still  far 
from  being  satisfactorily  understood. 

The  fact  that  young  girls  do  not  usually  conceive  until  after  the  ap- 
pearance of  the  menses,  and  the  extreme  rarity  of  impregnation  after  their 
cessation,  rendered  it  natural  for  the  earlier  observers  to  suppose  that  con- 
ception could  not  occur  without  menstruation,  and  that  the  menstrual  flow 
represented  the  female  semen.  This  view,  however,  was  soon  abandoned, 
and  the  discharge  was  regarded  as  a  process  of  purification. 

It  was  not  until  the  doctrine  of  periodical  ovulation  had  been  estab- 
lished by  the  work  of  Gendrin,  Negrier,  Bischoff,  Pouchet  and  others,  that 
definite  ideas  could  be  formulated  concerning  the  relation  between  ovula- 
tion and  menstruation.  From  that  time  on,  however,  it  was  generally  be- 
lieved that  menstruation  was  brought  about  by  the  ripening  of  the  Graafian 
follicles;  that  the  two  processes  occurred  almost,  if  not  quite,  simultane- 
ously, and  that  menstruation  should  be  considered  as  analogous  with  the 
heat  or  rut  of  animals. 

This  doctrine  culminated  in  1865  with  the  appearance  of  Pfliiger's 
article  upon  the  significance  and  cause  of  menstruation,  in  which  he  stated 
that  the  flow  resulted  from  a  reflex  stimulation,  which  owed  its  origin 
to  the  pressure  exerted  bv  the  growing  follicle  upon  the  nerves  of  the 
ovary.  This  theory  obtained  almost  immediate  acceptance,  and  for  years 
was  the  predominant  belief;  upon  it  was  based  our  method  of  calculating 
the  expected  date  of  confinement,  the  rule  being  to  date  the  beginning  of 
pregnancy  from  the  last  menstrual  period. 

Pfliiger's  theory,  however,  was  somewhat  shaken  by  the  work  of  Leo- 
pold, Prochownick,  and  De  Sinety,  whose  careful  studies  of  the  condition 
of  ovaries  removed  at  operation  proved  conclusively  that  the  two  processes 
were  not  necessarily  synchronous,  but  might  occur  quite  independently  of 
one  another,  and  accordingly  ovulation  could  not  be  considered  the  unvary- 
ing cause  of  menstruation.  Clinical  experience  also  lent  further  probabil- 
ity to  this  view,  since  it  has  shown  that  ovulation  and  subsequent  preg- 
nancy might  take  place  without  menstruation,  as  was  demonstrated  by  the 
instances  of  conception  occurring  before  the  first  menstrual  period  and 
after  the  menopause,  as  well  as  during  lactation,  when  the  menstrual  flow 
is  usually  absent.     Moreover,  a  few  cases  were  recorded  in  which  preg- 


MENSTRUATION    AND   OVULATION  77 

nancies  had  occurred  in  such  rapid  succession  ihai  menstruation  did  not 
occur  for  years.  Ahlfeld  has  reported  the  case  of  a  woman  who  gave  birth 
tn  numerous  children,  bul  did  nol  menstruate  until  her  thirty-second  year; 
and  one  of  Leviot's  patients  did  no1  menstruate  for  fourteen  years,  and  ye\ 
during  that  time  became  pregnanl   no  Less  than  four  times. 

Sigismund,  Lowenhardt,  Lowenthal,  and  Aveling  next  advocated  the 
theory  that  ovulation  preceded  niciistruat  ion,  and  that  the  latter  was  due 
to  the  failure  oi  conception.  Aveling  designated  the  process  as  nidation 
ana  aenidation,  and  considered  thai  a  menstrual  decidua  was  formed  each 
month  for  the  reception  of  the  fertilized  ovum,  and  thai  if  conception  did 
ttol  occur  it  degenerated  and  was  cast  off  with  the  menstrual  flow.  The 
gist  of  these  theories  was  tersely  expressed  by  Powers  in  the  dictum, 
"  \V_onu'n_inciigtxuntiL-boj^iusc'  they  do  not  conceive."  This  view  was  also 
adopted  by  His  and  most  embryologistsasirue,  for  a  certain  number  of 
eases  at  least.  They  found  on  examining  ova  which  were  nominally  of  the 
same  age,  as  estimated  from  the  last  menstrual  period,  that  some  presented 
a  stage  of  development  several  weeks  in  advance  of  the  others;  they  held. 
therefore,  that  this  difference  covtld  be  explained  only  by  supposing  that 
the  former  resulted  from  conception  soon  after  the  last  menstrual  period, 
and  the  latter  from  conception  just  before  the  first  period  missed.  This 
view  is  also  confirmed  by  the  reproductive  history  of  the  orthodox  Jewesses, 
who  are  noted  for  their  fertility.  According  to  their  laws  women  are  con- 
sidered unclean  during  the  entire  menstrual  period  and  the  seven  days  fol- 
lowing it.  so  that  in  them  conception  probably  occurred  just  before  the 
firsl   missed  menstrual  period. 

In  1894,  Leopold  and  Mironoff  made  an  extended  study  of  the  condi- 
tion of  ovaries  removed  at  operation  from  42  women  whose  menstrual  his- 
tory had  been  carefully  noted.  In  30  cases  they  found  that  menstruation 
and  ovulation  were  synchronous;  in  11  menstruation  occurred  without  any 
trace  of  ovulation;  while  in  1  case  ovulation  occurred  in  the  middle 
of  the  intermenstrual  period. 

Strassmann,  in  a  recent  study,  has  more  or  less  rehabilitated  the 
original  Pfliiger  theory,  by  showing  that  rut  can  be  produced  by  injecting 
gelatine  into  the  ovaries  of  animals.  His  views  have  received  a  certain 
sort  of  confirmation  from  the  discovery  by  Elisabeth  Winterhalter  of  a 
sympathetic  ganglion  in  the  ovary. 

From  the  evidence  before  us,  we  must  conclude  that  the  two  process"  - 
usually  occur  about  the  same  time,  but  that  one  not  infrequently  ante- 
dates the  other  by  a  few  days;  while  in  exceptional  cases  they  may  occur 
quite  independently. 

Some  years  ago  Stevenson  advanced  the  so-called  menstrual-wave 
theory,  which  has  been  accepted  by  Johnstone.  Webster,  Ott,  and  others. 
According  to  this  idea,  the  metabolic  processes  in  women,  present  a  dig=- 
tinct  rhythm,  and  gradually  increase  in  intensity  up  to  the  time  of  ihe 
menstrual  flow,  when  they  suddenly  drop  and  reach  their  lowesl  point: 
afteTThis  they  gradually  rise  again  and  attain  their  maximum  intensity 
just  before  the  next  menstrual  period,  thus  indicating  that  the  entire 
process  is  under  some  central  control,  and  that  neither  menstruation  nor 


78  OBSTETRICS 

ovulation  are  directly  dependent  upon  one  another,  but  upon  some  general 
and  as  yet  unknown  cause. 

The  results  following  various  operations  upon  the  genital  tract  tend  to 
show  that  menstruation  is  dependent  upon  the  presence  of  the  ovaries,  but 
that  ovulation  may"~take  place  without  tlie  presence  of  the  uterus;  as  it  is 
generally  admitted  that  the  complete  removal  of  both  ovaries,  which  neces- 
sarily stops  ovulation,  is  always  associated  with  cessation  of  the  menses. 
On  the  other  hand,  the  total  removal  of  the  uterus,  while  associated  with 
abolition  of  the  menstrual  flow,  exerts  no  effect  upon  ovulation,  as  is  mani- 
fested by  the  regular  occurrence  of  the  so-called  menstrual  molimina. 

A  number  of  observers  have  attempted  to  show  that  menstruation  may 
occur  independently  of  ovulation,  basing  their  contention  upon  the  occa- 
sional continuance  of  menstruation  after  the  removal  of  the  ovaries.  This 
conclusion,  however,  is  fallacious,  as  in  such  cases  either  the  ovaries  had  not 
been  completely  removed,  or  an  accessory  ovary  was  present.  The  now 
well-established  fact  that  a  very  small  portion  of  ovary  will  suffice  for  ovu- 
lation has  been  demonstrated  by  the  occurrence,  in  rare  instances,  of  preg- 
nancy after  the  removal  of  both  ovaries  by  competent  operators,  two  cases 
of  which  have  lately  been  reported  by  Gordon. 

Such  observations  conclusively  demonstrate  the  fallacy  of  the  view  ad- 
vanced by  Tait,  Johnstone,  and  Savage,  that  menstruation  is  regulated  by 
the  so-called  menstrual  nerve,  and  that  its  persistence  after  operation  was 
due  to  the  fact  that  this  nerve  had  not  been  included  within  the  ligature. 

Ordinarily,  the  Fallopian  tubes  take  no  part  in  the  menstrual  function, 
and  in  none  of  my  specimens  were  there  any  traces  of  a  bloody  fluid  in 
them.  Occasionally,  however,  the  tubal  mucosa  may  share  in  the  process, 
as  has  been  shown  by  the  experience  of  Thompson,  who  recently  reported 
a  case  in  which  a  pyosalpinx  had  ruptured  through  the  abdominal  wall, 
leaving  a  fistulous  opening  which  did  not  heal,  and  through  which  a 
slight  amount  of  bloody  fluid  exuded  at  each  menstrual  period. 

Migration  of  the  Ovum. — The  mechanism  by  which  the  ovum  gains 
access  to  the  tube  after  escaping  from  the  ruptured  follicle  is  a  question  of 
extreme  interest,  and  one  which  has  given  rise  to  a  great  deal  of  discussion. 
The  process  is  readily  understood  in  those  animals  in  which  the  ovaries 
are  more  or  less  completely  inclosed  in  a  peritoneal  sac  into  which  the  tube 
opens;  but  in  women,  and  in  animals  in  which  the  ovary  projects  freely  into 
the  peritoneal  cavity,  the  question  presents  greater  difficulties  and  has 
not  as  yet  received  a  thoroughly  satisfactory  solution. 

As  we  have  already  shown,  the  fimbriated  extremity  of  the  tube  lies  in 
the  neighbourhood  of  the  ovary,  but  is  not  necessarily  in  direct  contact 
with  it,  the  only  organic  connection  between  the  two  structures  being 
furnished  by  the  fini^ria  ovarica,  which  is  attached  to  the  upper  or  tubal 
pole  of  the  ovary. 

Numerous  theories  have  been  advanced  to  explain  the  manner  in  which 
the  ovary  enters  the  tube.  Eouget  believed  that  the  latter  became  en- 
gorged with  blood  at  the  menstrual  period,  and  that  as  a  result  of  its  be- 
coming erectile,  the  fimbria?  applied  themselves  to  the  portion  of  the  ovary 
in  which  the  ripe  follicle  was  situated — so  that  after  its  rupture,  the  ovum 


MIGRATION   OF   THE  OVUM  79 

was  immediately  taken  up  by  the  fimbriated  extremity  of  the  tube.  This 
view,  however,  has  been  abandoned,  as  ii  is  difficult  to  suppose  that  the 
tube  could  instinctively  pick  out  the  exacl  portion  of  the  ovary  to  which 
it  should  apply  itself.  KLehrer  believed  that  the  ovum  was  ejected  from 
the  follicle  at  the  time  of  rupture,  with  sufficient  force  to  be  tin-own 
directly  into  the  fimbriated  end  of  the  tube.  This,  the  so-called  ejacula- 
tion theory,  for  a  time  enjoyed  considerable  vogue,  but  has  likewise  been 
abandoned. 

At  present  it  is  generally  believed  that  the  cilia  upon  the  fimbriated  end 
o\'  the  tube  give  rise  to  a  current  in  the  capillary  layer  of  fluid  which 
lies  between  the  various  pelvic  organs,  so  that  the  ovum,  on  escaping 
from  the  follicle,  is  taken  up  by  the  current  and  wafted  towards  one  or 
the  other  tube,  whence  it  is  carried  to  the  uterus.  The  correctness  of  this 
view  has  been  substantiated  by  the  experimental  work  of  Pinner,  Jani,  and 
Lode'  The  former  injected  cinnabar  and  the  latter  the  ova  of  ascarides 
into  the  peritoneal  cavity  of  animals,  and  found  that  they  made  their  way 
to  the  pelvis,  where  they  were  taken  up  by  the  tubes,  through  which  they 
were  carried  to  the  uterus,  and  eventually  appeared  in  the  vagina.  This  ex- 
perimental evidence  is  re-enforced  by  the  fact  that  in  certain  amphibians 
huge  tracts  of  the  peritonaeum  become  covered  by  the  ciliated  epithelium 
shortly  before  the  time  of  ovulation.  It  is  more  than  likely,  however,  that 
a  considerable  proportion  of  the  ova  which  escape  from  the  ruptured  fol- 
licle fail  to  gain  access  to  the  tubes,  but  remain  in  the  peritoneal  cavity 
where  they  perish. 

In  1844,  Bischoff  directed  attention  to  the  fact  that  not  infrequently  in 
animals  possessing  bicornuate  uteri  one  finds  that  the  corpora  lutea  are 
in  one  ovary,  while  the  embryos  are  developed  in  the  uterine  horn  on  the 
opposite  side.  He  supposed  in  such  cases  that  the  fertilized  ova  had  come 
from  the  ovary  in  which  the  corpora  lutea  were  found,  and  had  made  their 
way  into  the  cornu  of  the  opposite  side  instead  of  into  the  one  corre- 
sponding to  the  ovary  from  which  they  came.  This  process  he  designated 
as  mii/ration  of  the  ovum. 

The  possibility  of  such  an  occurrence  in  women  was  first  carefully 
studied  by  Kussmaul,  who  stated  that  it  might  be  brought  about  in  two 
ways:  either  by  the  ovum  making  a  circuit  through  the  pelvic  cavity  and 
thus  gaining  access  to  the  opposite  tube,  or  passing  down  one  tube,  trav- 
ersing the  uterine  cavity,  and  then  making  its  way  up  the  opposite  tube. 
The  former  he  designated  as  external,  the  latter  as  internal,  migration 
of  the  ovum. 

External  migration  of  the  ovum  is  not  infrequently  observed,  whereas 
there  is  considerable  discussion  as  to  the  possibility  of  the  occurrence  of 
internal  migration.  We  are  unable  to  ascertain  how  frequently  external 
migration  takes  place  in  normal  uterine  pregnancies,  though  it  is  probably 
by  no  means  rare.  On  the  other  hand,  its  occurrence  has  been  rejrieatedly 
demonstrated  in  cases  of  bicornuate  uteri,  and  those  presenting  a  rudiment- 
ary horn;  and  not  infrequently  in  normal  uteri,  when  one  tube  is  markedly 
diseased  and  the  other  more  or  less  normal,  as  in  cases  of  hydrosalpinx  and 
inflammatory  lesions  of  one  tube  associated  with  occlusion  of  its  fim- 
6 


80  OBSTETRICS 

briatecl  extremity.  In  such  cases  when  the  corpus  luteum  is  found  on  the 
side  of  the  diseased  tube,  it  is  inferred  that  the  ovum  gained  access  to 
the  uterus  through  the  normal  or  only  slightly  diseased  tube  of  the  opposite 
side.  Moreover,  the  same  event  has  not  infrequently  been  observed  in 
extra-uterine  pregnancy. 

External  migration  of  the  ovum  has  been  produced  experimentally  in 
animals  by  Leopold,  who  excised  one  ovary  and  the  opposite  tube,  and 
found  in  a  number  of  such  cases  that  the  animals  became  pregnant  after 
the  operation.  A  very  convincing  case  has  been  recorded  by  Kelly,  who 
removed  the  diseased  left  ovary  and  right  tube  from  a  patient,  leaving  the 
normal  right  ovary  and  left  tube  behind.  Fifteen  months  later  the  woman 
was  delivered  at  term,  and  seventeen  months  after  delivery  the  remaining 
tube  was  removed  for  a  ruptured  extra-uterine  pregnancy. 

I  have  examined  specimens  from  6  cases  of  extra-uterine  pregnancy, 
which  apparently  offered  incontrovertible  evidence  of  external  migration 
of  the  ovum,  the  corpus  luteum  being  found  in  the  ovary  of  one  side  and 
the  pregnancy  in  the  oj^posite  tube.  The  same  condition  was  beautifully 
exemplified  in  a  specimen  which  Dr.  H.  C.  Coe  sent  me  for  examination. 
In  this  case  the  right  tube  had  twice  been  the  seat  of  extra-uterine  preg- 
nancy. The  first  pregnancy,  which  dated  from  several  years  before,  was 
situated  in  the  isthmic  portion  of  the  tube,  the  foetus  having  become  con- 
verted into  a  lithopgedion  which  completely  blocked  the  lumen.  External 
to  this,  and  occupying  the  lateral  portion  of  the  tube,  was  a  freshly  rup- 
tured four  months'  pregnancy.  The  right  ovary  was  small,  atrophic,  and 
covered  by  adhesions,  while  the  left  contained  the  corpus  luteum  of  preg- 
nancy. It  was  apparent  in  this  case  that  the  ovum  must  have  been  fer- 
tilized, soon  after  leaving  the  left  ovary,  by  a  spermatozoon  which  had 
made  its  way  up  the  left  tube;  after  which  it  had  been  carried  to  the  right 
tube  and  had  passed  down  it  until  arrested  by  the  lithopaxlion,  when  it 
underwent  further  development. 

Satisfactory  evidence  has  not  yet  been  adduced  in  favour  of  the  occur- 
rence of  internal  migration  of  the  ovum,  and  it  is  hardly  possible  that  such 
proof  can  ever  be  brought  in  the  future,  though  its  theoretical  possibility 
cannot  be  denied.  Schaeffer  and  Yeit  have  conclusively  demonstrated 
that  the  specimens  which  were  formerly  relied  upon  to  establish  its  oc- 
currence are  open  to  other  and  simpler  explanations. 

Place  of  Meeting  of  the  Ovum  and  Spermatozoa. — During  coitus  the 
semen  is  deposited  in  the  vagina,  and  the  question  arises,  How  do  the 
spermatozoa  contained  in  it  make  their  way  into  the  uterus,  and  when  and 
where  do  they  come  in  contact  with  the  ovum? 

The  number  of  spermatozoa  contained  in  a  single  ejaculation  is  marvel- 
lous, and  has  been  estimated  by  Lode  at  226,257,900.  Various  explana- 
tions of  the  method  by  which  they  gain  access  to  the  uterine  cavity  have 
been  advanced,  the  most  widely  known  being  the  aspiration  thpory  nf  Litz- 
mann,  Wernich,  and  Beck,  and  the  mucus-plug  theory  of  Kristeller.  The 
first-mentioned  observers  held  that  the  external  muscles  of  the__aiterus 
conjj^^-^ar^iblvjliiringcoitiis  and  compress  the  uterine  cavity,  into  which 
the  spermatozoa  are  aspirated  wnen  relaxation  occurs."    Kristeller  believed 


PLACE  OF   MEETING   OF  THE  OVUM    AND  SPERMATOZOA  -1 

thai  at  the  heighl  of  the  orgasm  the  thick  tenacious  mucus,  which  la  usually 
found  in  the  cervix,  is  forced  down  for  a  short  distance  into  the  vagina, 
where  it  becomes  covered  with  spermatozoa,  after  which  it  returns  to  its 
original  position  and  carries  them  with  it. 

It  cannot  be  denied  thai  spermatozoa  may  gain  access  to  the  uterine 
cavity  in  either  of  these  ways  in  a  certain  uumber  of  cases;  bu1  in  the  i 
majority  of  instances  it  is  probable  thai  they  may  make  their  way  thither/ 
by  their  own  activity.  Thai  this  view  is  corred  is  demonstrated  by  the 
instances  of  pregnancy  following  imperfeci  coitus,  and  those  which  have 
been  observed  in  women  with  unruptured  hymens.  Furthermore,  it  has 
been  shown  by  Henle  thai  spermatozoa  can  move  at  quite  a  rapid  rate. 
being  ahle  to  travel  a  distance  of  1  centimetre  in  three  minutes 

It  was  formerly  taught  thai  impregnation  normally  occurred  in  the 
uterine  cavity,  and  it  was  believed  by  Tait.  Wyder,  and  other  observ<  rs 
that  conjugation  was  favoured  by  the  direction  of  the  currents  produced 
by  the  cilia  of  the  uterus  and  the  tubes,  the  former  being  directed  from 
below  upward,  and  the  latter  from  above  downward,  so  that  the  two 
met  in  the  upper  part  of  the  uterine  cavity.  Thus,  the  ciliary  cur- 
rent would  favour  the  entrance  of  spermatozoa  into  the  uterus,  while  ren- 
dering impossible  their  entry  into  the  tubes,  except  in  diseased  conditions. 
But  in  view  of  the  observations  of  Hofmeier.  Mandl,  and  others,  which 
show  that  the  ciliary  current  is  directed  from  above  downward,  in  the 
uterus  as  well  as  in  the  tubes,  it  is  apparent  that  this  theory  must  he  aban- 
doned, and  it  must  be  admitted  that  the  spermatozoa  have  to  make  headway 
against  the  current  from  the  time  they  enter  the  internal  os. 

It  is  probable  that  spermatozoa  can  nearly  always  he  found  in  the  tubes 
of  married  women,  into  which  they  make  their  way  by  their  own  motility. 
Living  spermatozoa  have  been  observed  in  the  tubes  of  women  by  Birch- 
Hirschfeld  and  Diihrssen,  and  it  is  a  well-known  fact  that  they  retain  their 
activity  in  the  tubes  of  the  bat  for  many  months.  Years  ago  Bischoff 
showed  that  they  could  be  found  on  the  surface  of  the  ovaries  of  animals 
for  a  certain  length  of  time  after  copulation,  and  the  occurrence  of  ovarian 
pregnancy  demonstrates  that  the  same  may  occur  in  women. 

From  the  evidence  available,  it  appears  to  be  tolerably  satisfactorily 
demonstrated  that  in  women  who  copulate  at  frequent  intervals  the  tube 
must  be  regarded  as  a  species  of  receptaculum  seminis,  in  which  spermato- 
zoa are  alwavs  present  and  waiting  for  the  ovum,  and  that  fertilization 
usually  occurs  in  the  tubeg  find  nnly  rarely  in  thp  ntems. 

LITERATURE 

Ahlfeld.     Lehrbuch  der  Geburtshiilfe.  II.  Aufl..  2.  1898. 

Alt.     Ueber  das  Vorkommen  und  die  Bedeutunsr  der  Menstruation  bei  der  Vnlkern  der 

Altenwelt.     Monatssehr.  f.  Geburtskunde.  vi,  161-179.  1855. 
Avelixg.     Obst.  Jour,  of  Great  Britain  and  Ireland.  July.  1874.  209. 
Beck.     How  do  the  Spermatozoa  enter  the  Uterus  !    American  Jour,  of  Obst..  viii.  353-391, 

1875. 
Btschoff.     Die  Entwiekelung  des  Kaninchen-Eies.  1842. 
See  literature  on  the  Anatomv  of  Ovaries. 


82  OBSTETRICS 

Birch-Hirschfeld.     Quoted  by  Zweifel,  Lehrbuch  der  Geburtshiilfe,  II.  Auii.,  20,  1889. 
Christ.     Das  Verhalten  der  Uterusschleimhaut  wahrend  der  Menstruation.    D.  I.,  Griessen, 

1892. 
Coe.     Internal  Migration  of  the  Ovum.     Trans.  Amer.  Gyn.  Soc,  xviii,  262-278,  1893. 
Duhrssen.     Lebendige  Spermatozoen  in  der  Tube.     Centralbl.  f.  Gyn.,  593,  1893. 
Pindley.     Anatomy  of  the  Menstruating  Uterus.     Amer.  Jour.  Obst.,  1902,  xlv,  509-512. 
Gebhard.     Die  Menstruation.     Veit's  Handbuch  der  Gyn.,  iii,  1-94,  1898. 
Gendrin.    Traite  philosophique  de  medecine  pratique.     Paris,  1839. 
Gordon.     Two  Pregnancies  following  the  Removal  of  Both  Tubes  and  Ovaries.    Trans. 

Amer.  Gyn.  Soc,  xxi,  104-108,  1896. 
Haller.     Quoted  by  Ahlfeld,  Lehrbuch,  II.  Aufl.,  1,  1898. 
Henle.     Lehrbuch  der  Anatomic 
His.    Anatomie  menschlicher  Embryonen,  1880. 
Hofmeier.     See  literature  on  Anatomy  of  Uterus. 
Jani.     See  literature  on  Anatomy  of  Uterus. 

Johnstone.     The  Menstrual  Organ.     British  Gyn,  Jour.,  November,  1886. 
The  Pathological  Aspect  of  Stevenson's  Wave.     Amer.  Jour.  Obst.,  xxxi,  662-668,  1895. 
The  Clinical  Importance  of  the  Menstrual  Wave.     Trans.  Amer.  Gyn.  Soc,  xxi,  57-65, 

1896. 
Kahlden.     Ueber  das  Verhalten  der  Uterusschleimhaut  wahrend  und  nach  der  Menstrua- 
tion.    Hegar's  Festschrift,  Beitrage  zur  Geb.  u.  Gyn.,  Stuttgart,  1889. 
Kehrer.     Die  Zusammenziehungen  des  weiblichen  Genitalcanals.    Beitrage  zur  vergleich. 

u.  exp.  Geburtskunde,  Heft  1,  1864. 
Kelly.     Operative  Gynecology,  vol.  ii,  189,  1898. 
Kennedy.     Edinburgh  Medical  Journal,  xxvii,  1085,  1882. 
Kristeller.     Berliner  klin.  Wochenschr.,  1871,  Nr.  27,  28. 
Kussmaul.     Von  dem  Mangel,  der  Verkummerung  und  Verdoppelung  der  Gebarmutter 

und  der  Ueberwanderung  des  Eies.     Wurzburg,  1859. 
Leopold.     Studien  iiber  die  Uterusschleimhaut.     Berlin,  1878. 
Die  Ueberwanderung  des  Eies.     Arch.  f.  Gyn.,  xvi,  22-44,  1880. 

Untersuchungen  iiber  Menstruation  u.  Ovulation.     Arch.  f.  Gyn.,  xxi,  347-408,  1885. 
Leopold  und  Mironofp.     Beitrag  zur  Lehre  von  der  Menstruation  u.  Ovulation.     Arch. 

f.  Gyn.,  xlv,  506-538,  1894. 
Leviot.     Ovulation  sans  menstruation  pendant  une  periode  de  14  ans.    Bull,  de  la  Soc. 

d'Obst.  et  de  Gyn.,  Paris,  1893,  202. 
Litzmann.     Wagner's  Handworterbuch  der  Physiologie,  iii,  53. 
Lode.     Wiener  klin.  Wochenschr.,  1891,  907. 

See  literature  on  Anatomy  of  Uterus. 
Lohlein.     Das  Verhalten  der  Uterusschleimhaut  wahrend  der  Menstruation.    Gynakolog. 

Tagesfragen,  Heft  2,  Nr.  6. 
Lowenhardt.     Die  Berechnung  und  die  Dauer  der  Schwangerschaft.     Arch.  f.  Gyn.,  iii, 

356-391,  1872. 
Lowenthal.    Eine  neue  Deutung  des  Menstruationprocess.    Archiv  f.  Gyn.,  xxiv,  169-261, 

1884. 
Mandl.     Beitrag  zur  Frage  des  Verhaltens  der  Uterusmucosa  wahrend  der  Menstruation. 

Arch.  f.  Gyn.,  Iii,  557-578,  1896. 
See  literature  on  Anatomy  of  Uterus. 
Meerdervoort.     Quoted  by  Gebhard. 
Moericke.     Die  Uterusschleimhaut  in  verschiedenen   Altersperioden  und  zur  Zeit  der 

Menstruation.     Zeitschr.  f.  Geb.  u.  Gyn.,  vii,  84-137,  1882. 
Negrier.     See  literature  on  Anatomy  of  Ovaries. 
Ott.     Gesetz  der  Periodicitat  der  physiologischen  Functionen  im  weiblichen  Organismus. 

Verh.  des  X.  internat.  med.  Congresses,  Bd.  Ill,  Abt.  viii,  33.  Berlin,  1891. 
Pfluger.     Ueber  die  Bedeutung  u.  Ursache  der  Menstruation.     Berlin,  1865. 


MENSTRUATION   AND  OVULATION  83 

Pinner.    See  literatim-  on  Anatomy  of  Uterus, 

Ploss.     Das  Weib  in  dor  Natur-  and  Vtflkerkunde,  IV.  AufL,  Bd.  I.  866-884,  1895. 

Pouchet.    See  literature  on  Anatomy  of  I  >  varies. 

Peochownii  k.     Fall  von  Menstruatio  praecox.    Archiv  f.  Gyn.,  .wii,  830-381,  L881. 

Rouget.    Recherches  sur  les  organes  erectiles  de  la  femme.    Jour,  de  la  Phvsioloeie  i 

320,  1858. 
Savage.    The  Female  Pelvic  Organs.    3d  ed.,  New  Vui-k.  lsso. 
Scii.vKFKEu.     Ueber  die  innere  Ueberwanderung  des  Eies.    Zeitschr.  f .  Geb  u  Gyn    .wii 

13-42,  1889. 

Sigismund.    Ideen  iiber  das  Wesen  der  Menstruation.    Berliner  klin   Wochenschr    1871 
824,  825. 

de  Sinett.    Recherches  sur  la  muqueuse  uterine  pendant  la  menstruation.    Gazette  med. 

de  Paris,  No.  7,  1881. 
Stevenson.    On  the  Menstrual  Wave.    Amer.  Jour.  Obst..  xv.  287-294,  1882. 
Steassmann.      Beitrage  zur  Lehre  von   der  Ovulation,  Menstruation  und  Conception. 

Archiv  f.  Gyn.,  lii.  184-23-1.  1896. 
Tait.     See  literature  on  Anatomy  of  Uterus. 

Thompson.     Zur  Frage  der  Tubenmenstruation.     Centralbl.  f.  Gyn.,  1898,  1227.  1228. 
Veit.     Die  Frage  der  inneren  Ueberwanderung  des  Eies.    Zeitschr.  f.  Geb.  u.  Gyn    xxiv 

327-355,  1892. 
Webster.     The  Biological  Basis  of  Menstruation.     Montreal  Med.  Journal,  April,  1897. 
Weenich.     Ueber  die  Erectionsfahigkeit  des  unteren  Uterusabschnittes,  etc.     Beitrage  zur 

Geb.  u.  Gyn.,  Berlin,  1872,  297-307. 
Westphalex.    Zur  Physiologie  der  Menstruation.    Archiv  f.  Gyn.,  lii.  35-70,  1896. 
Williams.     The  Normal  Structures  of  the  Uterine  Mucosa,  and  its  Periodical  Changes. 

Obst.  Journal  of  Great  Britain  and  Ireland,  1875. 
Winter iialter.     See  literature  on  Anatomy  of  Ovaries. 
Wyder.     See  literature  on  Anatomv  of  Ovaries. 


CHAPTER   IV 

MATURATION,   FERTILIZATION,   AND  DEVELOPMENT  OF  THE 

OVUM 


Formation  of  the  Foetal  Membranes. — In  the  present  work  we  shall  not 
attempt  to  trace  the  development  of  the  ovum  through  all  its  stages,  but 
shall  consider  only  those  changes  which  are  directly  concerned  in  the 
formation  of  the  foetal  membranes  and  the  placenta.  For  detailed  infor- 
mation concerning  the  general  development  of  the  embryo,  the  student  is 
referred  to  the  standard  works  upon  embryology. 

Maturation  of  Ovum. — The  ovum,  as  it  occurs  in  the  mature  Graafian 
follicle,  is  not  adapted  for  fertilization  and  further  development  until  it 
has  undergone  certain  changes  more  especially  noticeablein  its  nucleus, 
which  may  be  regarded  as  signs  ot  maturation.  The  process  has  not  as 
yet  been  proved  for  human  beings;  but,  as  it  has  been  observed  in  all 
the  lower  animals  which  have  been  studied,  it  is  reasonable  to  suppose  that 
it  also  occurs  in  man.    The  changes  are  supposed  to  begin  just  before  the 


-S 


Fig.  77.  Fig.  78. 

Figs.  77-79. — Formation  of  Polar  Body  (Sobotta).     X  500. 
«.,  nucleus  ;  V.,  vitelline  membrane  ;  Y.,  yolk  granules  ;  P.,  polar  spindle  ;  S.,  head  of  spermatozoon. 

rupture  of  the  follicle,  and  to  be  conjpleted  while  the  ovum  is  in  the  upper 
portion  ot  the  tuDe, 'though  occasionally  they  may  take  place  while  it  is 
still  within  the  ovary.  Sobotta  has  recently  made  an  exhaustive  study  of 
the  process  in  the  mouse,  and  it  is  from  his  article  that  most  of  our  state- 
ments are  taken. 

When  the  process  of  maturation  is  about  to  begin,  the  germinal  vesicle 
approaches  the  surface  of  the  ovum  and  appears  to  become  smaller,  while 
at  the  same  time  its  membrane'disappears.  It  gradually  becomelTless  and 
less  distinct,  until  finally  its  situation  is  indicated  by  a  clear  area  sur- 
roundedixy  deutoplasm,  which  is  traversed  by  many~raclialiing  linesT  In  a 
short  time  this  area  becomes  transformed  into  a  typical  caryocinetic  or 


MATURATION   OF  THE  nvr.M 


85 


mitotic  figure  (Fig.  77),  which  undergoes  the  usual  changes  and  soon  be- 
comes spindle-shaped.  The  spindle,  when  it  firsl  appears,  is  situated  tan- 
gentially  to  the  surface  of  the  ovum,  bul   later  turns  and  becomes  per- 


,'P2 


-—P. 


p.. 


m.p----\-> 


Fig.  80.  Fig.  81.  Fig.  82. 

Figs.   80-82.— Formation   of   Female    Peonucxeos   and   its   Fusion  with    .Mali.    Pronucleus 

(Sobotta).     X  500. 
P.,  polar  body  ;  P.2,  second  polar  body  ;  f.p.  female  and  m.p.  male  pronucleus  ;  p.n.,  pronuclei  about 

to  fuse. 

pendicular  to  it.  The  chromatin  of  the  spindle  then  becomes  rearranged 
and  a  typical  dyaster  is  formed.  Division  rapidly  ensues,  and  the  new 
nucleus  nearest  the  surface,  with  the  portion  of  protoplasm  surrounding 
it.  is  cut  off  from  the  rest  of  the  ovum  and  comes  to  lie  between  it 
and  the  vitelline  membrane.    In  this  way  is  formed  the  first  polar  body. 

Within  a  short  time  similar  changes  take  place  in  the  remaining  por- 
tion of  the  nucleus  of  the  ovum,  and  a  second  polar  body  is  formed  and 
cast  off.  The  portion  of  the  original  nucleus,  which  remains 
within  the  ovum,  is  known  as  the  female  pronucleus. 

The  number  of  polar  bodies  which  are  cast  off  varies.  In 
most  animals  two  are  usually  found,  but  in  the  mouse,  ac- 
cording to  Sobotta,  it  is  exceptional  to  find  more  than  one. 
The  polar  bodies  are  the  result  of  typical  division  of  the 
ovum,  and  their  whole  history  forces  us  to  regard  them  as 
cells  homologous  with  ova.  Consequently,  when  two  polar 
bodies  are  formed,  the  female  pronucleus,  and  more  espe- 
cially the  chromatin  bodies,  which  are  constant  and  can  be 
counted,  represent  half  of  the  original  germ  nucleus  before 
the  polar  bodies  were  given  off,  and  half  of  the  number  of 
nuclei  characteristic  of  the  given  species.  The  ovum  is  a 
quarter  of  the  primitive  germ  cell,  which  in  maturing  has 
been  broken  up  by  two  divisions  into  two  polar  bodies  and 
the  ovum. 

Various  theories  have  been  advanced  by  Minot,  Weis- 
mann,  Kollmann.  and  others  in  explanation  of  the  process, 
but  none  of  them  are  very  satisfactory.  In  the  present  state 
of  our  knowledge  it  must  be  admitted  that  we  are  ignorant 
of  its  cause  or  significance,  and  must  be  content  with  the  knowledge  that 
its  occurrence  is  a  necessary  preliminary  to  the  fertilization  and  further 
development  of  the  ovum. 


Fig.  S3. — Human 
Spermatozoa. 

ft.,  head ;  c,  inter- 
mediate por- 
tion; t..  tail. 


86 


OBSTETRICS 


Fertilization. — By  fertilization  we  understand  the  union  of  a  spermato- 
zoon and  the  mature  ovum.  Each  spermatozoon  consists  of  three  portions 
— the  head,  tail,  and  intermediate  portion.  The  head  is  somewhat  tri- 
angular in  shape  and  flattened  from  side  to  side;  it  contains  a  certain 
amount  of  chromatin,  which  is  derived  from  the  mother  cells  of  the  tes- 
ticle (Fig.  83).    Each  spermatozoon  must  be  regarded  as  a  distinct  cell,  and 


Fig.  85.  Fig.  86. 

Changes  in  the  Segmentation  Nucleus  (Sobotta).     X  500. 
P.,  polar  body  ;  s.n.,  segmentation  nucleus. 

each  germ,  as  compared  with  the  ovum,  represents  a  fourth  part  of  the 
primitive  germ  cell,  from  which  four  sperms  arise  by  two  divisions.  Its 
structure  is  one  half  of  that  characteristic  of  the  nuclei  of  the  species. 
Interpolated  between  the  long  tail  and  the  head  is  a  small  cylindrical 
body,  the  intermediate  portion,  to  which  is  attached  the  tail.  The  sper- 
matozoa are  endowed  with  marked  motility,  derived  from  the  rapid  vibra- 
tion of  their  tails,  and,  according  to  Henle,  can  traverse  a  distance  of  1 
centimetre  in  three  minutes. 

As  has  already  been  jjointed  out,  the  spermatozoa  and  ovum  usually 
come  together  in  the  lateral  portion  of  the  tube,  which  may  be  regarded 
as  a  species  of  receptaculum  seminis,  although  in  rare  instances  the  meet- 
ing may  take  place  on  the  surface  of  the  ovary  or  even  in  the  Graafian 


Fig.  87.  Fig.  88.  Fig.  89. 

Figs.  87-89. — Formation  of  Mulberry  Mass  (Sobotta).     X  500. 


follicle,  as  is  demonstrated  by  the  occurrence  of  ovarian  pregnancy.  More- 
over, S'tratz  has  shown  that  in  Sorex  their  union  on  the  surface  of  the 
ovary  is  not  of  infrequent  occurrence. 

In  the  lower  animals  in  which  the  process  of  fertilization  has  been 
studied,  the  ovum  is  found  in  the  lateral  end  of  the  tube,  surrounded  by  a 
considerable  number  of  spermatozoa,  as  many  as  60  having  been  counted 


DKVKLOPMKNT   OF   THE   OVUM 


-7 


Fie.  90. — Blastodermic  Vesicle  of  Babbit 

(v.  Beneden,). 

cavity  of  vesicle  ;  ect..  primitive  ectoderm  ;  i.e.m., 
internal  cell  mass  :  z.p.,  zona  pellucida  :  e..  albu- 
minous envelope. 


about  a  single  ovum.    They  rapidly  penetrate  the  vitelline  membrane,  but 
it  appears  thai  only  one  of  them  makes  its  way  into  the  ovum,  and  that 
after  its  entry  the  superficial  por- 
tion of  the  latter  becomes  imper- 
vious to  other  spermatozoa. 

After  tlie  head  has  entered 
the  ovum  the  tail  rapidly  disap- 
pears, and  in  a  shorl  I  ime  aoth- 
ing  i>  left  .if  the  original  sper- 
matozoon hut  a  small  spindle- 
shaped  mass,  the  mule  pronucleus 
(Fig.  l!»).  This  rapidly  makes  its 
way  to  the  centre  of  the  ovum, 
where  it  meets  ami  fuses  with  the 
female  pronucleus  to  form  the 
segmentation  nucleus  (Figs.  81 
and  82).  It  is  therefore  apparent 
that  in  the  species  studied  half  of 
the  chromatin  of  the  segmenta- 
tion nucleus  is  derived  from  the 
original  nucleus  of  the  ovum,  and 
half  from  the  head  of  the  sper- 
matozoon. 

Development  of  the  Ovum. — Soon  after  the  appearance  of  the  seg- 
mentation nucleus,  caryocinetic  changes  take  place  within  it  and  give  rise- 
to  a  tvpical  nuclear  spindle,  which  is  soon  converted  into  a  dyaster,  to  be 
speedily  followed  by  the  division  of  the  ovuni  into  two  cells  (Figs.  85  and 
86).     Each  of  these  in  turn  divides,  giving  rise  to  four  cells,  though  So- 

botta's  investigations  on  the  mouse  show 
that  one  of  the  original  cells  segments 
earlier  than  the  other,  so  that  we  next 
have  three  cells.  This  process  of  cell  divi- 
sion or  segmentation  goes  on  until  the 
original  ovum  becomes  converted  into  a 
ma^s  of  cells,  which  is  designated  as  the 
morula  or  mulberry  ina*s  (Fig.  89). 

Fluid  soon  appears  in  the  niulberry 
mass  and  forces  the  cells  to  the  periphery, 
thus  giving  rise  to  a  vesicular  structure 
consisting  of  a  single  layer  of  cells  which 
surround  a  cavity  filled  with  fluid — the 
segmentation  cavity.  The  entire  struc- 
ture at  this  time  is  known  as  the  blastoder- 
mic vesicle,  which  in  the  rabbit  and  many 
other  animals  is  still  surrounded  by  the  vitelline  membrane  (Fig.  90),  where- 
as in  the  mouse  the  latter  disappears  before  the  formation  of  the  mulberry 
mass. 

In  a  short  time  a  collection  of  cells  can  be  noted  at  one  point  on  the 


-2. p. 


Fig.  91. — Maitmaliax  Blastodermic 
Vesicle  i  v.  Beneden  . 
ect.,  primitive  ectoderm :  i.c.m..  internal 
cell  mass  lembryonic  area) ;  z.p.,  zona 
pellucida. 


88 


OBSTETRICS 


inner  surface  of  the  blastodermic  vesicle.  This  is  known  as  the  internal 
cell-mass;  while  the  single  layer  of  cells  forming  the  wall  of  the  vesicle  is 
frequently  spoken  of  as  the  primitive  chorion  (Fig.  91).    When  viewed  by 

transmitted  light  the  internal  cell-mass  ap- 
pears darker  than  the  rest  of  the  surface  of 
the  blastodermic  vesicle,  and  hence  is  called 
the  macula  embryonalis.  Sections  made 
through  it  at  this  point  show  that  it  is 
composed  of  several  layers  of  cells,  those 
nearest  the  exterior  being  ectodermal,  and 
those  nearest  the  segmentation  cavity  en- 
todermal. 

This  stage  of  development  has  not  as  yet 
been  observed  in  the  human  ovum,  but  as  it 
has  been  demonstrated  in  the  ova  of  the  vari- 
ious  species  of  animals  which  have  been 
available  for  study,  there  is  no  doubt  that  it 
occurs  in  all  mammals.  These  changes  are  supjjosed  to  take  place  while 
the  ovum  is  making  its  way  through  the  tubes,  which  is  believed  to  occupy 
a  period  of  from  five  to  seven  days,  since  the  only  human  ovum  thus  far 
found  in  transit  through  the  Fallopian  tube  was  discovered  by  Hyrtl  in 
its  uterine  end  five  days  after  the  cessation  of  the  menstrual  period.  The 
earliest  human  ovum  appearing  in  the  uterine  cavity  was  recently  described 
by  Peters,  and,  although  he  considers  it  to  be  only  three  days  old,  cer- 
tainly presents  a  tolerably  advanced  stage  of  development. 

As  the  cells  composing  the  internal  cell-mass  proliferate,  they  give  rise 
to  a  round  or  oval  area  at  one  point  on  the  surface  of  the  blastodermic 


Fig. 


-Human  Ovum  (Keichert). 
X  6. 


e.a.,  embryonic  area  ;  v.,  villi. 


Fig.  93.  Fig.  04. 

Figs.  93,  94. — Embryonic  Area  of  Babbit  (Kollmaim).,    X  30. 
A.o.,  area  opaca  ;  A.p.,  area  pellucida  ;  B.v.,  wall  of  blastodermic  vesicle  ;  E.s.,  embryonic  shield. 


vesicle — the  embryonic  area — which  at  first  consists  of  two  layers  of  cells 
representing  the  ectoderm  and  entoderm  respectively.     One  of  the  earliest 
human  ova  showing  this  condition  was  described  by  Eeichert.     It  was  oval 
in  shape,  about  the  size  of  a  pea,  and  partially  covered  by  villi  (Fig.  92). 
Specimens  presenting  this  stage  of  development  are  readily  obtained 


DEVELOPMENT   OP   THE   nVl'M 


89 


Fig.  95. — Sei  tion  thb h  Embeyonk 

Shield  of  Sheep    Bonnet  . 
(<■/..  ectoderm  ;  ent.,  entoderm. 


i'  1-. .iii  the  lower  animals,  especially  rabbits.  In  them  the  embryonic  area, 
when  viewed  by  transmitted  light,  is  firs!  round,  bul  later  oval  in  shape, 
and  presents  a  dark  centre  and  a  light  periphery,  which  are  designated 
respectively  as  the  area 
i  paca  and  the  area  pellu- 
cida  (Figs.  93  and  94). 

The     embryonic     area 
soon  becomes  slightly  ele- 
vated   above    the    general 
surface   of   the   blastoder- 
mic vesicle,  and  now  forms 
what  is  known  as  the  em- 
bryonic shield;  its  differentiation  into  the  area  opaca  and  the  area  pellu- 
cida  is  due  to  the  varying  number  of  cells  composing  it,  inasmuch  as  they 
are  arranged  in  several  layers  in  the  former,  whereas  in  the  latter  only  two 
can  be  made  out.    A  few  hours  later  a  darker  zone  appears  at  one  end  of 

the  embryonic  shield  and 
soon  exceeds  it  in  size 
(Fig.  96).  This  is  the 
mesodermic  area,  which  on 
section  is  seen  to  be  made 
up  of  spindle-shaped  and 
triangular  cells.  Fig.  97, 
representing  a  section 
through  the  embryonic 
area  of  a  rabbit  at  this 
stage,  shows  distinctly 
that  it  is  made  up  of 
three  layers  —  ectoderm, 
mesoderm,  and  entoderm. 
The  mesodermic  area  rapidly  increases  in  size,  and  soon  forms  a  complete 
layer  inside  the  blastodermic  vesicle  just  beneath  the  ectoderm. 

A  little  later  there  appears  in  the  middle  of  the  embryonic  area  a 
slight  depression-^the  primitive  streak — which  is  bounded  on  either  side 
by  a  slight  elevation — the  primitive  folds.  Graf  Spee  has  described  a 
human  ovum  from  the  early  part  of  the  second  week,  which  presented  this 
stage  of  development.  In 
it  the  embryonic  area  was 
0.4  millimetre  long,  and 
the  primitive  streak  ex- 
tended throughout  its  en- 
tire length  (Figs.  98  and 
103).  A  little  later  a  sec- 
ond depression — the  med- 
ulla vij   groove — appears    in 

front  of  the  primitive  streak.  It  is  bounded  on  either  side  by  an  elevated 
fold — the  medullary  ridges — which  converge  anteriorly  to  form  the  head- 
folds.    The  medullary  groove  is  in  the  same  line  with  the  primitive  streak. 


Fig. 


Mesoderm: 


96. — Diagrams  showing  Extexsiox 
(Duval). 
A.o.,  area  opaca ;  A.p.,  area  pellueida ;  mes.,  mesoderm ;  P.s.. 
primitive  streak. 


•:v  -;:  ; 

- 

Fig.  9T. — Rabbit's  Ovum,  showing  Three  Layers  (Rabl). 
ect..  ectoderm  :  ent..  entoderm  :  mes..  mesoderm. 


90 


OBSTETRICS 


but  never  unites  with  it;  while  the  medullary  folds  diverge  posteriorly  and 
inclose  the  anterior  end  of  the  primitive  streak.     As  the  ovum  becomes 

older      the      medullary 
' '  i  J  V< --- ,  ^  groove    and    folds   rap- 

idly increase  in  size, 
while  the  primitive 
streak  remains  station- 
ary, so  that  in  a  short 
time  it  occupies  only  a 
small  portion  of  the 
embryonic  area. 

Graf  Spee  has  also 
described  a  human 
ovum  belonging  to  a 
stage  a  little  later  than 
that  represented  in  Fig. 


Fig.  98.- 


-Spee's   Human   Ovum,  Embryonic   Area,  0.4  Milli- 
metre Long.     X  24. 


A.,  amnion  ;  Bs.,  abdominal  pedicle  ;  C,  chorion  ;  c.e.,  chorionic 
epithelium :  cm.,  chorionic  mesoderm  ;  V.,  chorionic  villi ; 
y.,  yolk-sac. 


98,  in  which  the  em- 
bryonic area  was  2 
millimetres  long.  The 
structures  occupying  it 
are  clearly  shown  in 
Fig.  100.  The  medullary  groove  and  primitive  streak  are  not  in  the 
same  plane,  but  the  latter  is  bent  almost  at  right  angles  to  the  former  and 
occupies  the  inferior  end  of  the  embryonic  area.  Between  the  two  is 
a  small  opening,  the  neurenteric 
canal,  which  serves  to  connect  the 
ectoderm  with  the  entoderm. 

The  medullary  groove  and 
folds  result  from  the  prolifera- 
tion of  the  ectoderm,  and  from 
them  the  central  nervous  system 
is  developed. 

While  these  changes  are  taking 
place  on  the  surface  of  the  embry- 
onic area,  others  of  no  less  impor- 
tance are  going  on  in  its  depths, 
which  result  in  the  formation  of 
the  mesodermic  structure.  On 
either  side  of  the  medullary  canal 
can  be  observed  a  slight  thicken- 
ing— the  segmental  layer  (the 
Stammzone  of  the  Germans),  out- 
side of  which  is  a  thinner  layer — 
the  parietal  zone  (Fig.  101).  The 
segmental  layer  soon  becomes  di- 
vided up  into  a  number  of  more  or 

less  cuboidal  masses  of  tissue  on  either  side  of  the  medullary  groove,  which 
are  variously  designated  as  protovertebrce,  primary  segments,  or  mesoblastic 


Fig.  99. — Embryonic  Shield  of  Eabbit,  show- 
ing Primitive  Streak  and  Medullary 
Folds  (Kollmann).     X  28. 


DEVELOPMENT  OF  THE  OVUM 


91 


somites;  from  these  the  musculature  of  the  dorsal  portion  of  the  body  i-  de- 
veloped. The  parietal  zone  is  also  made  up  >>\'  mesoderm,  and  soon  becomes 
divided  into  two  layers  w  hich  inclose  a  cavity,  the  ccelome.  The  outer  layer  is 
covered  by  ectoderm,  and  is  designated  as  the  somatopleuve,  while  the  inner  is 
lined  by  entoderm  and  is  called  the  splanchnopleure.  From  a  pari  of  the  for- 
mer the  anterior  and  lateral  abdominal  walls  arc  developed,  while  in  main-  of 
the  lower  animals  its  greater  portion  gives  rise  to  the  chorion  and  amnion. 
Thus  far  we  have  considered  the  growing  ovum  as  seen  from  without; 
Inn  the  study  of  the  microscopical  sections  through  it  aid  us  si  ill  further 
in  understanding  its  development. 
Fig.  95  represents  a  section  through 
the  embryonic  area  at  an  early  period, 

~— H.f. 


M.f. 


-*7r"» 


c: 


Fig.  100. — Human  Embryo  2  Millimetres 
Long  (Graf  Spee).     X  30. 
.4..  amnion;   C,  chorion  ;  C.V.,  chorionic  villi; 
B.s.,  Bauchstiel  ;    M.g.,   medullary   groove ; 
X.c,  aeurenteric  canal ;  P.s.,  primitive  streak  ; 
)'.*..  yolk-sac. 


Fig.  101. — Chicken  Embryo  •with  Five  Seg- 
ments (Kollmann). 

H.f.,  head  fold ;  M.f.,  medullary  folds  ;  P.,  primi- 
tive streak  ;  P.s.,  primitive  segments ;  P.z., 
parietal  zone  ;  S.s.,  segmental  zone. 


and  shows  that  the  greater  part  of  the  blastodermic  vesicle  is  composed  of 
two  layers  of  cells,  the  ectoderm  and  the  entoderm.  In  the  region  of  the  em- 
bryonic area  the  ectoderm  is  arranged  in  several  layers,  whereas  the  ento- 
derm consists  of  a  single  layer.  Fig.  97  represents  a  section  through  the  em- 
bryonic area  of  a  rabbit  at  a  little,  later  stage,  and  shows  three  distinct  layers 
— ectoderm,  mesoderm,  and  entoderm.  In  Fig.  102  the  embryonic  area  of  a 
chicken  is  shown  at  a  still  later  period  of  development;  the  medullary  groove 
and  notochord  are  well  marked,  and  the  mesoderm  has  become  thickened 
to  form  the  segmental  layer. 


92 


OBSTETRICS 


Fig.  103  shows  a  section  through  Graf  Spee's  youngest  ovum,  in  which 
the  three  layers  are  clearly  differentiated,  and  the  dorsal  portion  of  the 


ect. 


ent. 

Fig.   102. — Cross-section  through  Chicken  Embryo  with  Seven  Segments  (Minot).     X  220. 

ect.,  ectoderm ;  ent,  entoderm  ;  mes.,  mesoderm ;  M.g.,  medullary  groove ;  N.,  notochord ; 

Seg,,  primitive  segment. 


embryo  is  covered  by  amnion.     Fig.  104  shows  a 
period,  with  a  well-defined  medullary  canal  and  a 


Fig.  103. — Cross-section  through  Gra.f  Spee's  Youngest  Ovum. 

E.A.,  embryonic  area  :  P.,  primitive  streak  ;  ect,  ectoderm ; 
ent,  entoderm  ;  mes.,  mesoderm. 


human  ovum  at  a  later 
marked  increase  in  the 
mesodermic  structures. 

From  the  ectoderm 
are  developed  the  cen- 
tral nervous  system 
and  the  cutaneous 
structures;  from  the 
mesoderm  are  derived 
the  muscular  and  cir- 
culatory portions  of 
the  body,  the  repro- 
ductive organs  and 
the  connective  -  tissue 
framework  of  the  va- 
rious other  organs; 
while  the  entoderm 
gives  rise  to  the  di- 
gestive tract  and  the 
organs  which  are  more 
or  less  intimately  con- 
nected with  it. 

In  the  chicken  and 
many  mammals  the 
chorion  and  amnion 
are  not  formed  until 
the  parietal  layer  of 
the  mesoderm  has  be- 
come well  developed 
and,  together  with  the 


FORMATION   OF   CHORION    AND    AMNION 


93 


ectoderm,  has  beeD  differentiated  into  the  somatopleure  and  splanchno- 
pleure;  but  in  all  of  the  very  early  human  ova  thus  far  described,  the  chorion 
and  amnion   are  well 

developed,   while   the  /^       *£  u       J^^       An, 

embryo  itself  is  in  a  /^>ii§§S8jV  <3f9 

very       riidimriitary     m<»     |  {jtT^l  ^%  ~    *'%,    X    mes. 

c  onditi  o  n  .     This        ^-S&  i*oV/«^,*»'A5,*v    •£   '  i^fe?*'V«;    -'      %  ect 
would  appear  to  indi-  'WW   iffe'* 

cate  that  in  man  and 
certain  mammals  they 
are  formed  in  a  man- 
ner different  from 
that  usually  described 
for  the  lower  animals. 
Amnion  and  Cho- 
rion in  the  Chick. — 
We  shall  now  briefly 
consider  the  forma- 
tion of  the  chorion  and  amnion  in  the  chicken  and  many  of  the  mammals. 
While  the  changes  which  we  have  just  described  are  taking  place  in  the 
embryonic  area,  the  entoderm  and  mesoderm  extend  around  the  interior  of 
the  blastodermic  vesicle,  so  that  in  a  short  time  its  walls  are  made  up  of 
three  layers,  except  in  the  region  of  the  embryonic  area,  where  quite  a 


5      A      C 


Fig.  104. — Section  through    Spse's  Older 

Ovum     End  of  Second  Week  . 

Am.,  amnion  ;  ect.,  ectoderm  :  me*.,  mesoderm  :  enk,  entoderm  ; 

M.,  medullary  groove. 


Fig.  105. — Diagram  showing  Longitudinal  Section  through  Mammalian  Embryo,  showing 

Formation  of  Amnion. 

number  are  present.    At  this  period  the  cavity  lined  by  entoderm  occupies 
the  greater  part  of  the  ovum  and  is  designated  as  the  yolk-sac. 

After  the  segmental  and  parietal  zones  have  been  developed,  and  the 


94 


OBSTETRICS 


latter  has  become  differentiated  into  the  somatopleure  and  splanclmopleure, 
the  formation  of  the  foetal  membranes  begins,  and  part  of  the  yolk-sac  is 
taken  up  into  the  embryo  to  form  the  intestinal  tract. 

At  either  end  of  the  embryonic  area  a  fold  of  somatopleure  makes  its 
appearance  and  gradually  arches  over  the  cephalic  and  caudal  extremities 
until  the  two  portions  meet  together  in  the  middle  and  thus  form  a 
double-layered  sac  which  surrounds  the  embryo.  The  inner  layer  con- 
sists of  ectoderm  within  and  mesoderm  without,  and  is  designated  as  the 
amnion;  the  outer  layer  consists  of  mesoderm  within  and  ectoderm  with- 
out, and  is  known  as  the  chorion;  while  the  cavity  between  the  two  is 
called  the  extra-embryonic  coelome.  According  to  Minot,  therefore,  "  the 
chorion  is  all  of  the  extra-embryonic  portion  of  the  somatopleure  which 
does  not  enter  into  the  formation  of  the  amnion."    While  the  outer  por- 


•\^ 


Fig.  106.- 


-Diagram  showing  Transverse  Section  through  Mammalian  Embryo,  showing 
Formation  of  Amnion. 


tions  of  the  somatopleure  are  taking  part  in  the  formation  of  the  amnion 
and  chorion,  those  nearer  the  embryo  become  folded  inward  and  downward 
to  form  its  abdominal  walls. 

Coincident  with  these  changes  the  splanchnopleure  becomes  separated 
throughout  the  entire  extent,  of  the  ovum,  so  that  it  completely  surrounds 
the  yolk-sac,  which  then  becomes  a  definite  organ  lined  within  by  ento- 
derm and  without  by  mesoderm,  and  separated  from  the  chorion  by  the 
coelome. 

As  the  body  walls  become  developed  at  the  bead  and  tail  ends  and  sides 
of  the  embryo,  the  upper  portion  of  the  yolk-sac  becomes  included  within 
its  body,  where  it  forms  the  primitive  gut  and  becomes  more  or  less  sepa- 
rated from  the  rest  of  the  yolk-sac  by  the  infolding  of  the  somatopleure 
which  forms  the  abdominal  walls.  This  condition  of  affairs  is  well  illus- 
trated in  Figs.  105  and  106. 

Almost  as  soon  as  the  formation  of  the  hindgut  is  begun,  a  small  off- 


PLATE   IV. 
TV.  ¥         UE. 


BL 


& 


Fib. 


Jap. 


BLs.  '■' 


Emb. 


5   *        J* 


■  I  S 


-sSH** 


IS 

:. »#. 


.  ■:      8J  •      ..  .    f/'i    ..'.;     %  .       \   Jc       »  „•  .  .  -     -        ,       ' 


G 


Mes.  j      ,:v:'*  !  j 

G       j,         D.C.     Cap. 

PETEKS'S   OVUM.      X  50. 


Coi 


BIS.,  blood  spaces;  Cap.,  capillary;  Comp.,  compact  layer  of  decidua ;  D.  C,  decidual  cells;  Emb., 
beginning  embryo  ;  Fib.,  mass  of  fibrin  covering  point  of  entry  of  ovum  into  decidua  ;  Mes., 
connective-tissue  layer  of  chorion ;  Ref.,  decidua  reflexa;  Syn.,  syncytium ;  Tr.,  trophoblast ; 
U.  E.,  uterine  epithelium. 


FORMATION   OF  CHORION    AND    AMNION  95 

shool  extends  from  its  caudal  extremity,  which  is  made  up  of  entoderm 
internally  and  mesoderm  externally.  This  is  the  allantois,  which  under- 
goes marked  developmenl  in  many  animals,  bul  in  man  remains  in  a  rudi- 
mentary condition.  In  many  animals  it  becomes  converted  into  a  vesicular 
structure  which  soon  occupies  a  considerable  portion  of  the  extra-ein- 
bryonic  ccelome,  until  it  reaches  the  inner  surface  of  the  chorion,  to  which 
it  applies  itself,  and  with  which  it  soon  becomes  intimately  connected. 
The  umbilical  vessels  spread  out  over  the  allantois,  through  which  they 
are  ultimately  distributed  to  the  chorion  and  thus  bring  about  intimate 
vascular  connections  between  the  vessels  of  the  embryo  and  those  of  the 
mother. 

When  the  allantoic  vesicle  is  highly  developed,  as  in  the  calf,  it  also 
serves  another  important  function,  as  into  it  a  large  part  of  the  urinary 
secretion  of  the  embryo   is   passed. 

Formation  of  Chorion  and  Amnion  in  Man. — The  earliest  human  ova 
thus  far  described  possess  a  well-developed  chorion  and  amnion,  while  the 
embryo  itself  is  in  a  far  more  rudimentary  stage  of  development  than  is 
the  case  with  most  mammals  at  the  time  of  the  formation  of  the  somato- 
pleure  and  splanchnopleure.  -Accordingly,  it  appears  reasonable  to  sup- 
pose that  these  structures  are  formed  in  man  in  a  manner  different  from 
that  which  obtains  for  most  of  the  lower  animals. 

Peters's  specimen,  which  was  found  in  the  uterus  of  a  woman  who 
committed  suicide  three  days  after  missing  her  menstrual  period,  is  the 
youngest  human  ovum  writh  which  we  are  acquainted.  It  measured  1.6  X 
€.8  X  0.9  millimetre  in  its  various  diameters,  and  presented  a  well-devel- 
oped chorion  and  a  very  small  amnion.  Plate  IV  represents  a  section 
through  the  portion  of  decidua  in  which  it  was  embedded,  and  shows  that 
the  chorion  is  made  up  of  two  layers — a  thin,  inner  layer  of  connective 
tissue  which  is  poor  in  cells  and  forms  the  lining  of  the  ccelomic  cavity, 
and  an  outer  layer  composed  of  many  layers  of  epithelial  cells.  These  cells 
form  a  capsule  of  varying  thickness  about  the  periphery  of  the  ovum,  and 
are  designated  as  the  trophoblast,  which  in  Peters's  opinion  represents  the 
primitive  ectoderm  of  the  ovum.  The  majority  of  the  cells  are  distinctly 
epithelial  in  appearance  and  possess  well-marked  roundish  or  cuboidal 
bodies  and  vesicular  nuclei.  Scattered  between  them  are  masses  of  proto- 
plasm which  show  no  sign  of  division  into  individual  cells,  and  contain 
irregularly  shaped,  darkly  staining  nuclei.  The  trophoblast  has  invaded 
the  surrounding  decidual  tissue  and  opened  up  numerous  blood-vessels,  so 
that  many  comparatively  large  blood  spaces  have  been  formed  in  it. 

From  the  underlying  connective  tissue  of  the  chorion,  numerous  small 
processes  project  into  the  trophoblast  and  represent  the  earliest  stages  in 
the  formation  of  chorionic  villi. 

Merttens,  Reichert,  Leopold,  and  Spee  have  all  described  ova  from  the 
second  week  of  pregnancy,  none  of  which  exceeded  4  millimetres  in  diam- 
eter. Each  possessed  a  well-developed  chorion  with  typical  branching  villi. 
The  ova  of  Reichert  and  Spee  were  cast  off  as  early  abortions,  while  those 
of  Merttens  and  Leopold  were  found  in  the  uterus,  the  former  being  dis- 
covered accidentally  in  the  scrapings  obtained  by  curettage,  and  the  latter 


96 


OBSTETRICS 


Fig.  107.  —  Seven-  to  Eight  - 
days'  Human  Ovum  (Leopold). 


in  a  uterus  removed  for  carcinoma;  both  were  completely  surrounded  by 
decidual  tissue.  Fig.  92  gives  a  representation  of  Eeichert's  ovum,  which 
is  lenticular  in  shape  and  surrounded  at  its  equator  by  short  villi.  Fig. 
109  represents  a  section  through  Leopold's  ovum,  and  shows  that  it  is  sur- 
rounded by  villi  which  are  in  contact  with  the 
decidua  serotina  and  reflexa.  In  all  of  these  ova 
the  chorion  consists  of  a  membranous  sac  com- 
posed of  mesoderm  within  and  ectoderm  without, 
from  whose  periphery  numerous  villi  project 
which  are  covered  by  two  layers  of  epithelium. 

From  the  study  of  these,  which  are  the  young- 
est ova  at  present  at  our  disposal,  it  is  apparent 
that  definite  information  concerning  the  devel- 
opment and  origin  of  the  human  chorion  is  still 
lacking,  though  it  is  probable  that  the  earliest 
stages  in  its  formation  are  completed  while  the 
ovum  is  still  in  the  tube.  Furthermore,  it  is 
highly  probable  that  the  changes  which  result 
in  its  formation  are  among  the  very  first  which 
the  human  ovum  undergoes,  and  that  the  chorionic  epithelium  corresponds 
to  the  primary  ectoderm  of  the  blastodermic  vesicle. 

Ivollmann  believes  that  the  ovum,  by  the  time  it  reaches  the  uterus, 
is  surrounded  by  a  distinct  chorion  possessing  short  but  definitely  formed 
villi;  while  Euge  and  Peters  hold  that  the  villi  do  not  appear  until  after 
the  implantation  of  the  ovum  upon  the  decidua.  Further  particulars  con- 
cerning the  structure  of  the  chorion  will  be  given  later. 

Nor  have  the  earliest  stages  in  the  formation  of  the  amnion  been 
observed  in  the  earliest  human  ova  yet  obtainable,  inasmuch  as  in  all  of 
them  a  closed  amniotic  sac  had  already  been  formed  which  arched  over 
the  embryonic  area.  In  Peters's  ovum  the  amnion  was  represented  by  a 
closed,  flattened  sac,  which  was  almost  in  contact  with  the  embryonic  area 
on  the  one  side  and  with 
the  connective-tissue  lay- 
er of  the  chorion  on  the 
other  (Fig.  110). 

The  ovum  from  the 
second  week,  described 
by  Graf  Spee,  gives  us 
important  information 
concerning  the  amnion, 
and  although  it  does  not 
present  the  earliest  stages 
in  its  formation,  it  en- 
ables us  to  theorize  as  to 

its  origin.  The  entire  ovum  in  this  case  measured  6X4-5  millimetres  in 
diameter,  and  possessed  a  -  well-developed  chorion,  a  portion  of  which  is 
shown  in  Fig.  98.  Projecting  from  one  point  of  its  interior  is  a  small 
vesicular  structure — the  beginning  embryo. 


Fig.  108. — Two-weeks'  Human  Ovum  (Leopold). 


FORMATION    nl'   CIlnKln.N    AND   AMNION 


'.'7 


Pig.  1 1 1  represents  a  section  through  the  same  ovum,  and  shows  clearly 
the  relations  of  its  various  parts.  The  embryo  is  attached  to  the  inner 
surface  of  the  chorionic  membrane  by  a  mesodermic  pedicle,  which  repre- 
sents the  earliesl  stage  of  the  abdominal  pedicle  (the  Bauchstiel  of  the  Ger- 
mans), which  is  the  precursor  of  the  umbilical  cord.  The  greater  portion 
of  the  embryo  is  occupied  by  the  yolk-sac.  from  one  end  of  which  a  small 
process,  lined  by  entoderm,  extends  into  the  pedicle,  which  must  be  con- 
sidered as  a  rudimentary  allantois.  Occupying  one  side  of  the  pedicle 
js  a  small  cavity  Lined  by  a  single  Layer  of  epithelium,  which  corresponds 


.»■ 


w 


Fig.  109. — Microscopic  Section,  showing  Seven-days'  Ovum  Embedded  in  Decidua  and  Scr- 
rounded  by  Decidua  Eeflexa  (Leopold). 


to  the  amnion.  On  one  side  of  this,  again,  is  a  mass  of  cells  arranged  in 
several  layers,  which  represents  the  embryonic  area,  in  which  there  is  a 
primitive  streak  0.1  millimetre  long.  It  is  apparent  from  this  specimen  that 
the  amnion  could  not  have  resulted  from  the  formation  and  fusion  of  the 
two  folds  of  somatopleure,  as  is  usually  stated,  for  the  embryonic  area  is  in 
a  far  too  rudimentary  state  to  admit  of  such  an  explanation. 

Figs.  100  and  112  represent  an  older  ovum  which  was  also  described  by 
Graf  Spee,  and  which  he  believed  belonged  to  the  third  week  of  pregnancy. 
In  it  the  relations  are  essentially  the  same,  except  that  the  outlines  of  the 
embryo  are  clearly  indicated  and  all  the  parts  are  larger.  The  amnion 
appears  as  a  flattened  sac,  which  is  closely  applied  over  the  dorsal  surface  of 
the  embryonic  area. 


98 


OBSTETRICS 


Graf  Spee,  in  describing  his  youngest  ovum,  stated  that  it  was  pos- 
sible that  the  amnion  might  be  formed  by  an  inversion  of  a  portion  of 
the  wall  of  the  original  blastodermic  vesicle,  and  the  recent  investigations 


Sp 


mes 

.    .   '^v  ■>,■  '  ^s>  -      % 


Fig.  110. — Portion-  or  Petees's  Ovun,  Highly   Magxifeed,  shotvkg  Early    Stage  in  Bevel- 

opiLENT  or  Embryo. 

A.,  amnion  ;   C,  chorion  ;  ect,  ectoderm  ;  ent.,  entoderm  ;  mes.,  mesoderm  ;  E.S.,  embryonic  shield 

Y.S.,  yolk-sac  ;  Sp.,  portion  of  coelum. 


of  Selenka  upon  the  monkey  tend  to  confirm  this  view.  Fig.  113,  repre- 
senting a  section  through  a  very  young  monkey  embryo,  shows  an  earlier 
stage  of  development  than  Graf  Spee's  youngest  ovum;  here  the  amnion 
is  represented  ~hy  an  inversion  from  the  surface  of  the  blastodermic  vesicle. 
It  is  only  necessary  to  suppose  that  the  upper  margins  of  the  inverted 


Fig.  111. — Section  through  Spee's  Youngest  Ovum,  shown  ix  Fig.  98.     X  24. 

c,  chorionic  membrane  ;  ect,  ectoderm ;  mes.,  mesoderm  ;  a.m.,  amnion  ;  e.,  beginning  embryo  :  bs., 

abdominal  pedicle  ;  all.,  allantois  ;  y.s.,  yolk-sac. 

portion  of  the  ectoderm  had  become  adherent  in  order  to  produce  a  condi- 
tion similar  to  that  observed  in  Spee's  ovum. 

Structure  of  the  Chorion. — In  its  very  earliest  stages,  and  while  the  ovum 
is  still  in  the  tube,  the  chorion  probably  consists  of  the  single  layer  of  ecto- 


STRUCTURE   ()F   Till-:   <  IK  >KI<  >.\ 


9t» 


dermal  cells  forming  the  wall  of  the  blastodermic  vesicle,  which  soon  be- 
comes  lined  by  a  tnesodermic  layer.  In  the  uterus,  however,  as  shown 
by  the  researches  of  Eubrecht,  Eeukelom,  and  Peters,  the  chorionic  epi- 
thelium rapidly  proliferates  and  forms  the  many-layered  trophoblast.  In 
n-  earliest  stages  the  chorion  is  probably  a  smooth  membranous  sac  with- 
out villi:  but  in  a  short  time  buds  of  connective  tissue  make  their  way 
into  the  trophoblasi  and  give  rise  to  rudimentary  villi. 

Fig.  Ill  represents  a  section  through  the  chorion  from  a  seventeen- 
davs'-old  pregnancy.  In  it  can  be  distinguished  two  portions — the  chori- 
onic membrane  and  the  villi  projecting  from  it.  The  chorionic  mem- 
brane consists  of  two  layers — the  inner  of  connective  tissue,  the  outer 


Fig.  112. — Sectiox  through  Huhax  Ovoi,  shown  en  Fig.  100  I  Spee). 
all.,  allantois ;   c.e..  chorionic  epithelium;    cm.,  chorionic  mesoderm;   Bs..  abdominal  pedicle;  E., 
beginning  embryo ;  ent..  entoderm ;  n.c,  neurenteric  canal :  p.s.,  primitive  streak  ;  v.,  chorionic 
villi ;  res.,  vessels  in  wall  of  yolk-sac. 


of  epithelium.  Its  connective  tissue  is  composed  of  spindle-  and  star- 
shaped  cells  embedded  in  a  mucoid  intercellular  substance,  and  at  this 
period  does  not  contain  blood-vessels.  Its  epithelium  is  arranged  in  two 
layers:  an  inner  one  adjoining  the  connective  tissue,  which  is  composed  of 
sharply  marked  cuboidal  or  roundish  cells  with  clear  protoplasm  and 
lightly  staining  vesicular  nuclei,  and  an  outer  layer  made  up  of  coarsely 
granular  protoplasm,  which  shows  no  signs  of  division  into  cells,  and 
through  which  are  scattered  irregularly  shaped,  darkly  staining  nuclei. 

Each  villus  arises  from  the  chorionic  membrane  as  a  single  stem,  giv- 
ing origin  to  numerous  branches  which  result  in  a  more  or  less  arborescent 
form,  the  complexity  of  which  increases  with  advancing  age.     The  villi 


100 


OBSTETRICS 


c.vr. 


£-— 


-— - C.y_ 


■-D 


A 


consist  of  a  connective-tissue  stroma  and  an  epithelial  covering,  the  former 
being  continuous  with  and  analogous  in  structure  to  the  connective  tissue 
of  the  chorionic  membrane,  while  the  epithelium  is  composed  of  the 
same  two  layers. 

Projecting  here  and  there  from  the  surface  of  the  villi  are  epithelial 
buds,  usually  consisting  of  a  mass  of  protoplasm  which  is  not  divided  into 

distinct  cells,  and  which,  when 

seen    in    cross    or    tangential 

j^      „--v  section,    resemble    giant    cells. 

These  buds  indicate  prolifera- 
tion of  the  outer  layer  of  the 
chorionic  epithelium,  and  rep- 
resent the  first  stage  in  the 
development  of  new  villous 
branches.  Here  and  there  in 
the  spaces  between  the  villi, 
larger  and  smaller  masses  of 
small,  clear  cells  with  vesicu- 
lar nuclei  are  seen.  The}r  are 
usually  described  as  decidual 
islands,  and  are  supposed  to 
represent  sections  through  de- 
cidual septa,  which  project 
upward  towards  the  chorionic 
membrane.  It  is  more  than 
probable,  however,  that  they 
are  really  masses  of  trophoblast 
which  have  not  been  converted 
into  villi. 

In  early  ova  the  embryo  is 
connected  with  the  connective- 
tissue  layer  of  the  chorion  by 
a  mesodermic  pedicle,  which 
was  first  described  by  His  as  the 
abdominal  pedicle  (Bauchstiel). 
In  it  can  be  observed  a  small 
process  of  entoderm  which 
represents  an  extension  of 
the  hindgut,  and  which  cor- 
responds to  the  allantois  of 
lower  vertebrates.  Through 
the  abdominal  pedicle  the  um- 
bilical vessels  of  the  embryo 
make  their  way  to  the  in- 
terior of  the  chorion,  which  then  becomes  vascularized. 

For  our  first  definite  information  concerning  the  structure  of  the  fully 
developed  human  chorion  we  are  indebted  to  Langhans,  who  showed  that 
it  was  made  up  of  four  layers:  a  gelatinous,  a  fibrillar,  a  vascular,  and  an 


--3 


-^5^  $& 
Fig.  113. — Section  through  Young  Ovum  of  Hylo- 
bates,  showing  FORMATION  of  Amnion  (Selenka). 
X8. 

A.,  amnion  ;  a.,  amniotic  pedicle ;  B.,  blood-vessel ;  C, 
chorion  ;  C.V.,  chorionic  villi  ;  D.,  decidua;  E.,  em- 
bryo ;  J.,  point  of  inversion  of  blastodermic  vesicle  ; 
Int.,  Intervillous  space  ;  Y.S.,  yolk-sac. 


STRUCTURE   OF   THE   CHORION 


101 


epithelial  layer.  The  gelatinous  is  the  innermost  layer  and  is  composed 
of  star-  ami  spindle-shaped  connective-tissue  cells  embedded  in  a  mucoid 
intercellular  substance.  External  to  this  the  cells  become  more  fusiform  in 
shape  and  relatively  abundant,  so  that  the  membrane  assumes  a  more 
fibrillar  appearance.  Scattered  through  the  portion  just  outside  of  this 
second  layer  are  numerous  vessels,  both  arteries  and  veins;  while  still  more 
externally  comes  the  epithelial  covering,  which  is  composed  of  the  two 
layers  already  described  in  the  seventeen-days'-old  chorion. 

Projecting  from  the  outer  surface  of  the  chorionic  membrane  are  nu- 
merous villi,  which  at  first  are  pretty  equally  distributed  over  its  periphery. 
As  pregnancy  advances,  however,  they  become  more  abundant  over  the 
portion  which  is  in  contact  with  the  decidua  serotina,  the  site  of  the  future 


Fig.  114. — Section  throttgh  Chorion  of  Two-weeks.  Hitman  Ovoi.     X  50. 
>/,-..  stroma  ;  S.Z.,  Langkans"s  layer  ;  %»:,  syncytium. 

placenta.  This  portion  of  the  chorion  is  designated  as  the  chorion  fron- 
dosum,  while  the  remainder,  which  is  in  contact  with  the  decidua  reflexa, 
is  termed  the  chorion  Iceve,  since  the  villi  covering  it  eventually  undergo 
complete  degeneration. 

A  certain  number  of  villi  extend  from  the  chorionic  membrane  to  the 
underlving  decidua.  attaching  the  ovum  to  it,  and  hence  are  designated  as 
fastening  villi.  The  majority  of  the  villi,  however,  spring  from  the  chori- 
onic membrane  as  arborescent  structures,  whose  free  endings  do  not  reach 
the  decidua,  and  which  increase  in  complexity  as  pregnancy  advances. 

In  earlv  pregnancy  the  villi  are  short  and  plump  and  represent  simply 
the  main  stems,  which  later  give  off  numerous  branches  and  assume  an 
arborescent  appearance.    Thus,  sections  through  a  young  chorion  show  only 


102  OBSTETRICS 

a  few  large  villi,  while  those  through  an  older  one  are  filled  with  a  mul- 
titude of  smaller  villi.  This  change  in  appearance  is  due  to  the  increas- 
ing arborescence,  and  may  be  compared  to  what  takes  place  in  a  clump 
of  trees,  which  at  an  early  period  are  represented  by  a  number  of 
almost  isolated  trunks,  but  later  give  off  innumerable  branches  and 
twigs.  These  differences  have  been  particularly  emphasized  by  De  Loos, 
who  has  shown  that  with  a  little  practice  one  can  roughly  estimate  the 
age  of  the  chorion  by  its  appearance  on  section. 

The  stroma  of  the  chorionic  villi  is  made  up  of  connective  tissue  which 
varies  in  appearance  according  to  the  age  of  the  chorion.  In  the  earlier 
stages  the  cells  are  branching  in  shape,  and  are  separated  from  one  another 
by  a  large  amount  of  mucoid  intercellular  substance;  later  on  they  become 
more  spindle-shaped  and  more  closely  packed  together,  so  that  the  stroma 
assumes  a  denser  appearance  (Figs.  115  and  117).  After  the  first  few  weeks 
blood-vessels  appear  in  the  stroma,  and  in  the  later  months  of  pregnancy 
the  arteries  present  thick  walls  possessing  the  typical  three  layers.  The 
arteries  and  veins  extend  to  the  tips  of  the  villi,  where  they  break  up  into 


»  -  w  :  •      '    ^ 

:  €*v  '•  eft    "'  ■&  *: 


t* 


Fig.  115.  Fig.  116. 

Figs.  115-117. — Chorionic  Villi  at  Third  Week  axd  Third  ant>  Xixth  Months.     X  375. 

capillaries,  but  there  is  no  anastomosis  between  the  vascular  supply  of  the 
various  villi  any  more  than  between  the  branches  of  different  trees  in  a 
forest. 

The  epithelium  covering  the  villi  was  mentioned  by  Dalrymple  in  1842, 
but  was  first  definitely  described  by  Langhans  many  years  later.  The 
latter  pointed  out  that  it  was  made  up  of  two  layers  similar  to  those  which 
have  been  described  in  the  seventeen-days'-old  chorion.  The  inner  layer 
was  designated  as  the  cell-layer  (Zellschicht),  and  is  now  generally  known 
as  Langhans's  layer;  while  the  outer  layer  is  usually  known  as  the  syncytium. 
The  term  "  syncytium "  was  introduced  in  1893-'91  by  Kossmann  and 
Merttens,  although  the  characteristics  of  the  tissue  had  been  recognised 
years  before  by  Kastschenko.  who  described  it  as  Plasmodium. 

During  the  first  half  of  pregnancy  the  two  are  readily  distinguished, 
but  in  the  second  half  Langhans's  layer  becomes  more  and  more  indistinct, 
so  that  at  the  end  of  pregnane y  the  majority  of  the  villi  are  covered  only  by 
a  single  layer  of  syncytium.  Figs.  115,  116,  and  11?  give  a  good  idea  of  the 
successive  changes  in  the  stroma  and  epithelium  of  the  villi  at  different  ages. 

The  Origin  of  the  two  layers  of  chorionic  epithelium  has  given  rise  to 
a  great  deal  of  discussion,  but  it  has  been  established  by  the  work  of 


STRUCTURE  OF  THE  CHORION 


103 


i8  -Tr 


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5 
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r.  ;• 

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ft*  f 

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Langhans,  Kastschenko,  Minot,  Webster,  Heukelom,  His,  Ruge,  and  Peters 
that  they  are  both  of  foetal  origin,  and  .in-  derived  from  the  ectoderm. 
Peters  has  demonstrated  that  they  hoth  come  from  the  original  trophoblas- 
tic covering  of  the  ovum.  He  believes  that  this  was  originally  made  up 
of  individual  cells,  which,  however,  became 

converted  into  syncytium  where  they  came      '   ^  '  «.' •  j       ->. 

in  contact  with  the  maternal  blood.  ,  ,     ,#,  '  f.   » » 

Tin'  t'irtal  origin  of  the  two  layers  of        >  ••    v»t  t»      V 

chorionic  epithelium  has  also  been  con- 
firmed by  the  work  of  Hubrecht  for  the 
hedgehog,  Duval  for  dogs,  Franked  for 
many  species  of  animals,  and  Opitz  for  %  "  .  .  -» 
the  guinea-pig,  cat,  and  rabbit,  and  is  at 
present  the  prevailing  view. 

In  1893,  K'issmann  advanced  the  theory 
that  the  syncytium  was  derived  from  the 
epithelium  of  the  uterus,  while  Langhans's 
layer  represented  the  original  foetal  ecto- 
derm. His  work  was  apparently  confirmed 
by  Merttens  a  year  later,  who  showed  con- 
clusively that  a  certain  amount  of  uterine 
epithelium  was  converted  into  syncytium, 
and  thought  himself  justified  in  concluding 
that  it  grew  up  over  the  villi,  which  up  to 
that  time  were  covered  by  only  a  single 
layer  of  Langhans's  cells  or  f cetal  ectoderm, 
and  thus  gave  them  their  second  or  outer 
layer.  The  work  of  Kossmann  and  Mert- 
tens was  very  plausibly  set  forth  and  ac- 
companied by  numerous  excellent  illustra- 
tions, and  their  conclusions  were  soon 
adopted  by  many  authorities,  among  whom 
we  may  mention  Harchand  and  Kollmann. 
It  would  seem,  however,  that  this  view  is 
untenable,  inasmuch  as  the  work  of  Hu- 
brecht. Heukelom.  and  Peters  has  shown 
that  the  ovum  is  surrounded  by  the  many- 
layered  trophoblast  before  the  formation 
of  the  villi  begins,  and  that  the  syn- 
cytium represents  onlv  a  modification  of 
it.  Moreover,  it  must  be  remembered 
that  during  pregnancy  the  greater  part 
of  the  uterine  epithelium  gradually  loses 
its  cylindrical  shape  and  becomes  cuboidal  or 
disappears. 

On  the  other  hand,  it  must  be  admitted  that  the  small  areas  of  tvterine 
epithelium  mav  occasionallv  assume  a  distinctly  syncytial  appearance,  and 
not  a  few  of  my  specimens  confirm  this  view.    This  occurrence,  however, 


V 

cSfe 


./ 


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rV. 


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Fig.  IIS.  —  Tubal  Mucosa,  shotting 
Conversion  or  Epithelium  lsto  Syn- 
cytium. 

Normal  epithelium  on  left,  syncytium  on 
right  side. 

flattened,  and  eventually 


104 


OBSTETRICS 


must  be  regarded  as  the  exception,  and  even  when  portions  are  so  con- 
verted, satisfactory  evidence  has  not  been  adduced  to  show  that  the  tissue 
grows  up  over  the  villi  and  gives  rise  to  their  syncytial  covering.  The 
formation  of  syncytium  is  not  necessarily  characteristic  of  pregnancy,  and 
may  occur  in  other  conditions,  as  Gebhard  has  shown  that  similar  changes 
are  occasionally  observed  in  carcinoma  of  the  non-pregnant  uterus. 

The  theory  of  Kossmann  and  Merttens  is  only  one  of  a  large  number 
which  have  been  advanced  in  explanation  of  the  origin  of  the  chorionic 
epithelium.  Those  who  are  interested  in  the  subject  are  referred  to  the 
article  of  Waldeyer,  who  in  1890  was  able  to  arrange  in  ten  groups  the  nu- 
merous theories  which  had  been  advanced  up  to  that  time. 

Structure  of  the  Amnion. — In  the  very  early  stages  of  pregnancy,  as 
we  have  already  shown,  the  amnion  is  a  small  sac  which  arches  over  the 
dorsal  surface  of  the  embryo,  and  later  becomes  larger  and  completely  sur- 
rounds it.  At  first  the  amnion  is  minute  and  occupies  only  a  small  por- 
tion of  the  entire  ovum;  but  as  pregnancy  advances  it  increases  in  size, 
until  eventually  it  comes  in  contact  with  the  interior  of  the  chorion  and 
obliterates  the  extra-embryonic  portion  of  the  ccelome.  When  the  outer 
surface  of  the  amnion  has  applied  itself  to  the  inner  surface  of  the  chorion, 
the  two  membranes  become  slightly  adherent,  but  are  never  very  inti- 
mately connected,  for  even  at  tbe  end  of  pregnancy  they  can  be  readily 
separated  from  one  another. 

From  its  earliest  stages  the  amnion  consists  of  two  layers:  an  outer  layer 
of  mesoderm  and  an  inner  layer,  made  up  of  flattened,  almost  spindle- 
shaped  ectodermal  cells. 
The  mesodermic  layer 
eventually  becomes  con- 
verted into  mucoid-like 
tissue,  which  does  not 
contain  blood  -  vessels; 
while  the  ectodermal 
portion  changes  into  a 
single  layer  of  small  cu- 
boidal  epithelial  cells, 
which  by  their  origin 
represent  simply  an  ex- 
tension of  the  body 
walls  of  the  embryo. 

Soon  after  its  forma- 
tion, a  certain  amount  of 
clear  fluid  collects  with- 
the   amniotic    cavity 


~v 


Fig.  119. — Uterus  lined  by  Decidua,  containing  Seven 
Eight-days'  Ovum  (Leopold).     X  1. 


Ill 


— the  amniotic  fluid — 
which  increases  in  quan- 
tity as  pregnancy  advances.  The  amount  varies  within  wide  limits,  and 
according  to  Fehling  averages  about  600  cubic  centimetres  at  the  end  of 
pregnancy,  although  it  may  be  as  much  as  2,300  or  as  little  as  265  cubic 
centimetres.    Its  specific  gravity  ranges  from  1.002  to  1.028,  and  it  contains 


DECIDUA  LOS 

a  certain  amouril  of  albumin,  urea,  kivaiin.  and  various  sails.  The  origin 
and  function  of  the  amniotic  fluid  will  be  considered  when  we  take  up  the 
physiology  of  the  feel  us. 

Thus  far  we  have  been  describing  the  foetal  membranes.  Before  taking 
up  the  study  of  the  placenta,  it  will  be  necessary  to  consider  the  changes 
which  the  uterine  mucous  membrane  undergoes  to  prepare  ii  Tor  the  re- 
cepl ion  of  1  he  ovum. 

Decidua. — The  decidua  is  the  mucous  membrane  of  the  uterus  which 
has  undergone  marked  changes  under  the  influence  of  pregnancy,  to  lit  it 
for  the  implantation  and  nutrition  of  the  ovum.  It  is  so  named  from  the 
fad  thai  ii  is  cast  off  after  labour.  The  older  writers  usually  distinguished 
between  the  decidua  of  menstruation  and  that  of  pregnancy,  but  the  em- 


Fig.  120.  Fig.  121. 

Fk.<.  120,  121. — Diagrams  illustrating  Hunterian  Theory  of  Formation  of  Decidua  Eeflexa. 

ployment  of  the  former  term  is  no  longer  justified,  since  it  has  been  shown 
that  there  is  no  great  loss  of  tissue  at  the  menstrual  period. 

The  conversion  of  the  mucous  membrane  of  the  uterus  into  decidua 
occurs  shortly  after  the  fertilization  of  the  ovum,  though  we  are  unable  to 
state  exactly  when  the  process  commences,  inasmuch  as  a  fairly  well- 
marked  decidua  was  present  in  all  of  the  early  pregnancies  which  have 
thus  far  been  described,  being  well  developed  in  the  specimens  described 
by  Peters  and  Leopold,  which  belonged  to  a  three-  and  a  seven-  or  eight- 
days'  pregnancy  respectively. 

Very  shortly  after  conception,  the  smooth  velvety  endometrium  be- 
comes markedly  thicker  and  its  surface  is  indented  by  furrows  of  consid- 
erable depth,  which  give  the  entire  membrane  a  mamelonated  appearance. 
Under  the  magnifying-glass  numerous  small  openings  can  be  distinguished 
which  are  the  mouths  of  the  uterine  glands.  The  decidual  formation  is 
limited  to  the  body  of  the  uterus,  and  does  not  extend  below  the  internal 
os.  though  in  rare  instances,  as  in  the  cases  reported  by  von  Franque  and 
von  Weiss,  isolated  decidual  cells  are  found  beneath  the  cervical  epithe- 
lium. 


106  OBSTETRICS 

For  purposes  of  description  the  decidua  is  usually  divided  into  several 
portions:  that  lining  the  greater  part  of  the  cavity  of  the  uterus  heing  desig- 
nated as  the  decidua  vera;  that  beneath  the  ovum  as  the  decidua  serotina; 
while  the  portion  which  surrounds  the  ovum  and  shuts  it  off  from  the  rest 
of  the  uterine  cavity  is  known  as  the  decidua  reflexa. 

The  terms  reflexa  and  serotina  date  from  the  time  of  William  Hunter, 
who  gave  excellent  drawings  of  the  decidual  membrane  in  his  atlas.     Un- 
fortunately, the  author  died  just  after  its  appearance  and  before  the  com- 
pletion of  the  explanatory  text,  which  was  prepared  by  John  Hunter  and 
Matthew  Baillie,  who  considered  that  the  decidua  represented  a  fibrinous 
exudate  from  the  lining  membrane  of  the  uterus,  which  formed  a  com- 
plete cast  of  the  uterine  cavity  and  completely  covered  the  tubal  openings. 
They  supposed,  therefore,  that  when  the  ovum  reached  the  uterine  end  of 
the  tube  its  further  passage  was  opposed  by  the  decidua  vera,  which  it  was 
obliged  to  push  before  it  as  it  entered  the  uterus, 
whence  the  term  reflexa;  and  that  after  the  reflexa 
^BBk^  ~  >        nad-  been  pushed  forward,  a  new  exudate  was  devel- 

{      t  oped  behind  the  ovum,  to  which  the  term  serotina 

was  applied. 

This  conception  was  universally  accepted  until 
1846,   when   Weber   in   Germany,   and   Sharkey   in 
England,  demonstrated  that   the   decidua  was  not 
/}~p~% /'    -    •         an    exudate,    inasmuch    as   it    contained    glandular 
?!  structures  which  they   identified  with   the  uterine 

glands.    It  having  therefore  become  necessary  to  ex- 
plain the  formation  of  the  reflexa  in  a  different  man- 
Fin-    123 

_  ner,  it  was  assumed  that  the  ovum,  on  reaching  the 

Figs.  122,  123. — Diagrams  ,  »  -,.,  ..  . ,      , .        -.  ,        -,      .  ^ 

showing  Fokmatiox  uterus,  found  its  entire  cavity  lined  by  decidua  vera, 
of  Decidua  Beflexa  to  which  it  became  attached  at  a  point  on  the  an- 
(Coste).  terior  or  posterior  wall  somewhere  in  the  neighbour- 

hood of  the  fundus;  and  that  immediately  after  its 
attachment  the  vera  began  to  proliferate  and  to  form  a  wall  around  the 
ovum,  which  gradually  increased  until  it  completely  inclosed  and  sur- 
rounded it.  Notwithstanding  the  new  ideas  concerning  the  formation  of 
the  decidua,  the  terms  reflexa  and  serotina  are  still  retained,  though  in  the 
new  anatomical  nomenclature  of  His  they  are  designated  as  the  decidua 
capsularis  and  oasalis  respectively. 

Decidua  Vera. — The  microscopic  structure  of  the  decidua  vera  was 
first  studied  by  Hegar  and  Maier,  but  it  was  not  until  the  work  of  Fried- 
lander  and  Ivundrat  and  Engelmann  that  its  structure  was  definitely  un- 
derstood. Friedlander,  in  1870,  pointed  out  that  the  decidua  vera  was 
composed  of  two  portions:  a  compact  layer  superimposed  upon  a  spongy  or 
glandular  layer,  the  latter  being  nearer  to  the  muscular  wall  of  the  uterus, 
and  mainly  forming  the  thickness  of  the  membrane.  Furthermore,  he  was 
of  the  opinion  that  the  separation  of  the  decidua  at  the  time  of  labour 
took  place  at  the  junction  between  the  two  layers.  He  showed  that  the 
compact  layer  was  made  up  of  large  round,  oval,  or  polygonal  cells,  with 
large,    lightly    staining,    vesicular   nuclei — the    decidual   cells;    while    the 


I » K«  II'l'A    VERA 


107 


I — -      ->_ 


:;-:;:: 


spongy    layer    was    composed    of    the    dilated    and    hyperplastic    uterine 
glands. 

The  decidua  vera  increases  markedly  in  thickness  during  the  first  three 
or  four  months  of  pregnancy,  so  thai  at  the  end  of  that  time  it  has  attained 
a  thickness  of  about  1  centimetre.  Figs.  18  and  124  show  very  graphically 
the  difference  between  the  normal  endometrium  and  decidua  vera  from 
a  uterus  four  months 
pregnant.  After  the 
fourth  month,  owing 
to  the  marked  increase 
in  the  size  of  the  ute- 
rus, the  vera  gradual- 
ly becomes  thinner,  so 
that  at  term  it  is  rare- 
ly more  than  2  milli- 
metres thick. 

Under  the  micro- 
scope the  compact 
layer  is  seen  to  be 
made  up  of  somewhat 
closely  packed,  large, 
round,  oval,  or  polyg- 
onal cells,  which  are 
distinctly  epithelioid 
in  appearance,  and 
possess  round,  vesicu- 
lar nuclei,  which  stain 
but  slightly  with  the 
ordinary  reagents. 
When  the  tissue  has 
been  distended  by 
hemorrhage  or  cede- 
ma,  it  is  seen  that 
many  of  the  decidual 
cells  present  a  stellate 
appearance,  and  are 
provided  with  long 
protoplasmic  out- 
growths which  anasto- 
mose with  similar  pro- 
cesses from  neigh- 
bouring cells.  In  the  early  months  of  pregnancy  the  ducts  of  the  uterine 
glands  may  be  seen  traversing  the  compact  layer,  but  they  soon  disappear, 
so  that  in  the  later  months  all  trace  of  them  is  lost. 

The  spongy  layer  is  made  up  of  the  distended  and  hyperplastic  glands 
of  the  endometrium,  which  are  separated  from  one  another  by  a  minimal 
amount  of  stroma.  In  many  instances  the  glandular  hyperplasia  is  so 
marked  that  the  spongy  layer  suggests  an  adenoma  in  appearance.    At  first 


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Fig.  124. — Decidua  Vera.  Fourth  Mo>th.     X  16. 


108  OBSTETRICS 

the  glands  are  lined  by  typical  cylindrical  uterine  epithelium,  which,  how- 
ever, gradually  becomes  more  cuboidal  in  shape  and  undergoes  fatty  de- 
generation, and  is  cast  off  in  great  part  into  their  lumina.  A  certain 
amount  of  epithelium,  however,  remains  intact  throughout  pregnancy,  and 


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Vera, 

Fourth  Month.     X  420. 

from  it  the  endometrium  is  regenerated  after  labour.  In  many  instances 
the  stroma  between  the  dilated  glands  has  undergone  but  little  change, 
and  closely  resembles  that  of  the  non-pregnant  uterus. 

Under  the  influence  of  pregnancy,  the  surface  epithelium  covering  the 
decidua  gradually  loses  its  cylindrical  shape  and  becomes  cuboidal  or  flat- 
tened, sometimes  even  resembling  endothelium.  Klein  first  directed  atten- 
tion to  this  condition,  and  held  that  it  was  a  characteristic  microscopic 
evidence  of  pregnancy.  All  subsequent  investigators  have  confirmed  his 
observations. 

Fig.  125  represents  a  section  through  the  compact  layer  of  the  decidua 
vera  at  the  fourth  month,  while  Fig-.  126  shows  a  gland  with  its  surround- 
ing  stroma  from  a  non-pregnant  uterus,  drawn  under  the  same  magnifica- 
tion. On  comparing  them,  it  is. readily  seen  that  the  decidua  differs  from 
the  non-pregnant  endometrium  by  a  marked  increase  in  size  of  the  stroma 
cells,  and  a  marked  decrease  in  size  of  the  epithelial  cells. 

As  a  result  of  the  work  of  Hegar  and  Maier,  Leopold,  Minot,  and 
others,  it  is  now  generally  admitted  that  the  decidual  cells  are  derived 
from  the  stroma  cells  of  the  endometrium,  which  have  undergone  marked 
increase  in  size  but  only  slight  increase  in  number.  Euge  directed  atten- 
tion to  the  resemblance  which  they  bear  to  sarcoma  cells,  and  stated  that 
"  the  decidual  cell  represents  the  physiological  type  of  the  sarcoma  cell." 

The  connective-tissue  origin  of  the  decidual  cell  was  established  only 
after  prolonged  investigation,  and  has  been  further  re-enforced  by  observa- 


DECIDUA    REFLEXA 


L09 


tions  made  in  certain  cases  of  early  tubal  pregnancy,  in  which  decidual 
cells  may  be  seen  developing  in  the  smaller  folds  of  the  tubal  mucosa. 
Sued  specimens  show  clearly  that  they  are  derived  from  the  ordinary  con- 
nective-tissue cells  and  result  from  the  hypertrophy  of  pre-existing  units 
rather  than  from  their  proliferation.  Furthermore,  Schmorl,  Eunoshita, 
Lindenthal,  and  others  have  described,  in  women  dying  soo n  after  child- 
birth, small  uodules,  varying  from  structures  just  visible  t<>  the  oaked  eye 
to  bodies  1  in  2  millimetres  in  diameter,  which  arc  scattered  over  the  peri- 
tonaeum, covering  the  posterior  surface  of  the  uterus,  Douglas's  cul-de-sac, 
and  the  anterior  surface  of  the  rectum,  and  occasionally  also  over  the 
ovaries.  Schmor]  considers  that  these  structures  are  always  found  at  full- 
term  pregnancy,  and  has  demonstrated  that  they  are  made  up  of  decidual 
tissue.  But,  whereas  they  develop  beneath  the  peritonaeum,  it  is  evident 
that  they  must  be  derived  from  connective-tissue  cells. 

Before  the  true  nature  <>!'  the  decidual  cells  was  definitely  proved, 
various  theories  were  advanced  as  to  their  origin:  Hennig  believing  that 
they  were  derived  from  leucocytes.  Frommel  and  Overlach  from  the  uter- 


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Fig.  120. — Gland  and  Stroma  from  Nonpregnant  Endometrium.     X  420. 


ine  epithelium,  and  Ereolani  from  the  endothelium  of  the  blood-vessels. 
At  the  present  time,  these  views  are  of  interest  only  from  an  historical 
stand-point. 

Decidua  Reflexa. — Except  for  the  first  few  hours  after  its  entry  into 
the  uterus,  the  ovum  is  shut  off  from  the  rest  of  the  uterine  cavity  by  the 
decidua  reflexa.  which  forms  a  capsule  of  decidual  tissue  around  it.  Fig. 
119  shows  a  seven-days'  pregnancy  in  which  the  reflexa  is  quite  ap- 
parent, and  Fig.  127  a  seventeen-days'  pregnancy  in  which  it  is  well  de- 
veloped. 


110 


OBSTETRICS 


During  the  early  months  of  pregnancy  the  decidua  reflexa  does  not 
entirely  fill  the  uterine  cavity,  so  that  a  space  of  varying  size  exists  be- 
tween it  and  the  vera.  This  is  well  shown  in  Fig.  128,  which  represents 
a  section  through  a  six-  to  seven-weeks'  pregnant  uterus.  At  the  fourth 
month  of  pregnancy,  however,  the  growing  ovum  entirely  fills  the  uterine 


Fig.    127. — Seventeen-days'  Pregnant  Utektjs.     X    1.     (Anatomical    Museum   Johns    Hopkins 
University.)     Embryo  drawn  relatively  too  large. 

D.R.,  decidua   reflexa ;    D.S.,  decidua   serotina ;    D.  V.,  decidua   vera ;    E.,  embryo ;    O.L.,  ovarian 
ligament ;  E.L.,  round  ligament. 


cavity,  so  that  the  reflexa  and  vera  are  brought  into  intimate  contact,  and 
the  part  of  the  uterine  cavity  which  has  remained  unoccupied  up  to  this 
time  becomes  obliterated.  In  a  short  time  the  two  structures  fuse  to- 
gether, when  the  reflexa  gradually  degenerates  and  disappears.  This  view 
was  first  advocated  by  Minot,  and  appears  to  be  well  founded,  inasmuch  as 


DKt  IDIA    KKFLKXA 


11  1 


sections  through  tne  wall  of  the  full-term  uterus  outside  of  the  placental 
site  show  that  the  entire  decidua  is  only  2  to  3  millimetres  thick,  and 
no  trace  of  the  decidua  reflexa  can  be  discovered.    (See  Fig.   L33.) 

The  decidua  reflexa  usually  attains  its  greatest  thickness  ai  aboul  the 
second  month.  Sections  through  it  at  this  time  show  thai  it  is  made 
up  of  decidua]  cells  and  is  covered  on  it-  exterior  by  a  single  layer  of 
flattened  or  cuboidal  epithelial  cells;  while  internally  it  is  in  contact  with 
the  festal  villi,  and  at  no  lime  .-hows  any  trace  of  uterine  epithelium.  In 
its  Lowest  portion,  where  it  is  connected  with  the  vera,  a  W^w  --land-  may 
hi'  found,  w  hose  ducts,  when  they  are  present,  are  seen  to  open  only  upon 
the  outer  surface  of  the  membrane. 

Op  to  a  few-  years  ago  it  was  universally  believed  that  the  reflexa 
originated  from  the  proliferation  of  the  vera,  which  grew  up  around  and 
gradually  inclosed  the 

ovum.    Selenka,  how-  J" . __^^    -: 

ever,  pointed  out  that 
in  monkeys  and  in 
certain  other  animals, 
the  decidua  reflexa 
was  not  formed  in 
this  way.  but  that  the 
ovum  penetrated  the 
surface  epithelium 
and  burrowed  down 
into  the  depths  of  the 
vera,  almost  immedi- 
ately after  its  implan- 
tation, and  thus  came 
to  be  surrounded  by 
the  stroma  cells.  Ac- 
cording to  this  view 
the  reflexa  would  be 
merely  the  portion  of 
the  decidua  vera 
which  covers  the 
ovum.       Yon     Herff 

then  stated,  upon  theoretical  grounds,  that  possibly  a  more  or  less  simi- 
lar process  takes  place  in  human  beings.  He  believed,  however,  that  the 
ovum  did  not  become  implanted  upon  the  free  surface  of  the  vera,  but  sank 
down  into  one  of  the  depressions  by  which  the  latter  is  marked. 

It  was  not.  however,  until  Peters  described  a  specimen  representing, 
as  he  believed,  a  three-days'  pregnancy,  in  which  the  ovum  was  embedded 
in  the  decidua  vera,  that  anything  like  positive  proof  in  support  of  Selen- 
ka's  views  was  adduced  for  human  beings.  Plate  IV,  taken  from  a  section 
through  Peters's  three-days'  pregnant  uterus,  shows  distinctly  that  the 
ovum  has  burrowed  down  beneath  the  surface  of  the  decidua  vera  and  is 
lying  in  the  interglandular  stroma.  Such  pictures  clearly  indicate  that 
the  reflexa  is  not  formed  by  the  proliferation  of  the  decidua  vera  as  is 
8 


Fig.  128. — Six-week?"  Peegxaxt  Uterus     . 
with   Eloxgatiox    of    Cep.yix,    SHOW- 
ING    ExTEXT    TO    WHICH    ITS    CaVITY    IS 
OCCUPIED    BV   THE    OVCM.      X  %■ 

O.E..  external  os  ;  O.I.,  internal  os  :  D.V.. 
decidua  vera:  D.S..  decidua  serotina; 
D.R..  decidua  reflexa;  Emb.,  embryo; 
P.,  placenta. 


112 


OBSTETRICS 


generally  stated,  but  simply  represents  the  portion  of  it  which  covers  the 
ovum,  and  which  undergoes  passive  enlargement  as  the  latter  increases 
in  size.  I  have  not  had  an  opportunity  of  examining  the  pregnant  uterus 
in  its  earliest  stages,  hut  in  several  very  early  cases  of  tubal  pregnancy 
I  have  seen  conditions  which  tend  to  confirm  Peters's  views. 

Decidua  Serotina. — The  decidua  serotina  is  the  portion  of  the  decidua 
which  lies  immediately  beneath  the  ovum;  from  it  the  maternal  portion 
of  the  placenta  is  developed.    Broadly  speaking,  it  presents  the  same  gen- 

G  Fee. 


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Fi&.  129. — Decidua  Serotina,  showing  Mixture  of  Fcetal  and  Maternal  Cells.     X  To. 
(?.,  glaud ;  V.,  vessel :  F.ec,  fetal  ectoderm. 


eral  structure  as  the  decidua  vera,  except  that  it  has  been  invaded  by 
fcetal  tissue,  so  that  its  superficial  portions  are  composed  of  decidual  cells- 
and  foetal  ectoderm. 

Friedlander  and  Leopold  stated  in  their  original  monographs  that  giant 
cells  appeared  in  the  serotina  about  the  middle  of  pregnancy.  These, 
they  thought,  made  their  way  into  the  vessels  and  gave  rise  to  thrombosis. 
Their  interpretation,  however,  is  no  longer  accepted,  and  it  is  now  gener- 
ally believed  that  the  majority  of  the  so-called  giant  cells  are  not  of 


DEVELOPMENT  OF  THE  PLACENTA  113 

decidual  origin,  but  represent  portions  of  foetal  ectoderm-  the  so-called 
syncytium — which  have  made  their  way  down  into  the  decidua.  Fig.  L29, 
representing  a  section  through  the  decidua  serotina  in  the  Last  month  of 
pregnancy,  shows  clearly  thai  its  superficial  portions  are  composed  of  a 
mixture  of  both  foetal  and  maternal  cells. 

In  the  decidua  serotina  large  numbers  of  blood-vessels  are  observed. 
The  arteries  pursue  a  spiral  course,  and  usually  penetrate  the  entire 
thickness  of  the  membrane;  while  many  of  the  veins  become  markedly 
dilated  and  form  large  sinuses.  In  Fig.  129  two  small  vessels  may  be  seen 
which,  after  pursuing  their  course  through  the  superficial  layer  of  the 
serotina,  open  into  the  intervillous  spaces  of  the  placenta.  The  consid- 
eration of  the  vascular  connections  between  the  foetus  and  the  uterus,  how- 
ever, will  be  deferred  until  we  take  up  the  study  of  the  placenta. 

Development  of  the  Placenta. — When  the  fertilized  ovum  reaches  the 
uterus  it  finds  the  endometrium  transformed  into  decidua  in  anticipation 
of  its  reception.  At  this  time,  as  has  already  been  pointed  out,  the  ex- 
terior of  the  ovum  is  represented  by  the  chorionic  membrane,  whose  epithe- 
lium is  arranged  in  many  layers — the  trophoblast.  We  are  unable  to  state 
as  yet  whether  it  possesses  villi  or  not.  though  if  such  are  present,  they 
must  lie  in  a  very  rudimentary  condition. 

The  ovum,  as  a  rule,  becomes  attached  to  the  decidua  vera  covering 
the  anterior  or  posterior  wall  of  the  uterus,  somewhere  in  the  neighbour- 
hood of  the  fundus,  and  only  exceptionally  in  the  lower  portion  of  the 
uterine  cavity.  It  is  very  rarely  implanted  in  the  angles,  since  these 
present  only  a  slight  decidual  reaction  as  compared  with  the  anterior  and 
posterior  walls.  At  present  we  are  absolutely  ignorant  concerning  the 
factors  which  cause  the  arrest  of  the  ovum  at  a  given  point. 

There  are  two  theories  as  to  what  occurs  immediately  after  the  im- 
plantation of  the  ovum  upon  the  decidua  vera.  According  to  the  one 
recently  promulgated  and  advocated  by  Peters,  the  trophoblast  soon  de- 
stroys the  surface  epithelium  of  the  decidua.  so  that  the  ovum  almost 
immediately  comes  in  contact  with  its  stroma,  into  which  it  rapidly  bur- 
rows (Plate  IV).  According  to  the  older  view,  which  has  obtained  universal 
acceptance  until  recently,  and  which  has  been  considered  in  detail  by  Euge 
and  His.  the  ovum  becomes  attached  at  some  point  on  the  surface  of  the  de- 
cidua vera,  which  immediately  begins  to  proliferate  around  it  and  soon  sur- 
rounds it  as  the  decidua  reflexa. 

The  evidence  at  our  disposal  renders  it  probable  that  Peters's  explana- 
tion is  correct,  especially  as  the  same  process  has  been  observed  by  Selenka 
in  the  monkey,  by  Opitz  in  the  guinea-pig.  and  upon  theoretical  grounds 
was  advocated  by  von  Herff  for  human  beings.  Under  these  circumstances 
the  reflexa  would  simply  represent  the  portion  of  the  decidua  vera  which 
covers  the  ovum,  its  further  growth  being  passive  and  due  to  the  force 
exerted  by  the  growing  ovum.  This  view-  has  also  been  adopted  by  Leo- 
pold. Marehesi.  and  Bott,  who  consider  that  the  seven-days'-old  ovum  de- 
scribed by  the  former  was  probably  implanted  in  this  manner. 

My  own  observations  tend  to  show  that  this  is  the  course  of  events  in 
tubal  pregnancy,  as  in  several  instances  I  have  found  the  ovum  embedded 


114  OBSTETRICS 

in  the  wall  of  the  tube  and  separated  from  its  lumen  by  a  thin  layer  of 
tissue.  Several  drawings  illustrating  this  condition  will  be  found  in  the 
chapter  on  Extra-uterine  Pregnancy.  At  first  I  was  inclined  to  regard  such 
findings  as  evidence  of  the  develojDment  of  the  ovum  in  a  diverticulum  from 
the  lumen  of  the  tube;  but,  after  the  appearance  of  Peters's  monograph, 
more  careful  examination  of  my  specimens  led  me  to  believe  that  my  former 
conclusion  was  incorrect. 

In  a  short  time,  no  matter  what  the  mode  of  implantation  may  have 
been,  the  ovum  becomes  completely  surrounded  by  decidua,  the  portion 
separating  it  from  the  uterine  cavity  being  known  as  the  reflexa,  and  that 
immediately  beneath  it  as  the  serotina.  Almost  immediately  after  the 
implantation  of  the  ovum,  its  trophoblast  begins  to  proliferate  and  in- 
vade the  surrounding  decidual  tissue,  as  was  shown  by  the  work  of 
Hubrecht,  Heukelom,  and  Peters.  As  it  does  so,  it  breaks  through  the 
walls  of  maternal  capillaries,  from  which  the  blood  escapes  and  forms 
cavities,  which  are  bounded  partly  by  trophoblast  and  partly  by  decidua 
(Plate  IV).  As  the  process  goes  on,  more  vessels  are  opened  up,  so  that  in 
a  short  time  the  trophoblast  presents  a  sieve-like  apj)earance  due  to  the 
presence  of  large  numbers  of  blood  spaces  filled  with  maternal  blood.  As 
a  result,  the  trophoblastic  cells  become  compressed  into  irregularly  shaped 
masses  of  varying  size,  some  of  which  extend  from  the  surface  of  the  ovum 
to  the  surrounding  decidua,  and  afford  the  epithelial  basis  from  which  the 
villi  are  developed. 

The  maternal  blood  spaces  established  in  this  manner  represent  the 
earliest  stages  in  the  formation  of  the  intervillous  blood  spaces  of  the 
future  placenta,  and  were  abundantly  present  in  the  early  ova  examined 
by  Peters  and  Leopold.  Coincidently  with  their  formation,  the  irregularly 
shaped  masses  of  trophoblast  are  invaded  by  connective-tissue  offshoots 
from  the  chorionic  membrane,  and  are  thus  converted  into  villi.  The  cells 
surrounding  them  become  arranged  in  two  layers,  the  inner  corresponding 
to  Langhans's  layer,  the  outer  one  being  composed  of  syncytium. 

As  we  have  already  indicated,  a  considerable  number  of  the  primary 
villi  extend  from  the  chorionic  membrane  to  the  surrounding  decidua, 
while  the  majority  project  freely  into  the  blood  spaces.  The  former  are 
designated  as  fastening  villi  (Haftzotten),  and  serve  to  attach  the  ovum 
to  the  decidua.  Where  they  come  in  contact  with  the  latter,  the  tropho- 
blast at  their  tips,  which  is  now  designated  as  chorionic  epithelium, 
undergoes  marked  proliferation,  and  like  the  roots  of  a  tree  invades  the 
decidual  tissue  still  further,  until  the  two  structures  become  firmly  united. 
The  proliferated  trophoblast  may  be  observed  in  placentas  in  all  stages 
of  development,  and  is  represented  by  what  are  usually  known  as  the 
cell  nodes  or  cell  columns.  Their  formation  was  carefully  studied  by  Heuke- 
lom in  the  early  ovum  which  he  described. 

During  the  first  few  weeks  of  pregnancy,  branching  villi  project  from 
the  entire  periphery  of  the  ovum,  as  is  well  seen  in  the  figures  taken  from 
Leopold's  work.  They  come  in  contact  not  only  with  the  decidua  sero- 
tina, but  also  with  the  reflexa;  so  that  intervillous  blood  spaces  surround 
the  entire  ovum,  as  is  particularly  well  shown  in  the  section  through 


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g.c.      d.i.  v: 

SECTION  THEOUGH  FOUR  MONTHS'  PLACENTA,  SHOWING  JUNCTION   OF 

CHORION   AND   DECIDUA.      X  56. 

a  F.,  canaHzed  fibrin;  C.  N.,  cell  nodes;  D.,  decidua  serotina;  D.  I.,  decidual  island;  G.  C,  giant 

cell;   I.S.,  intervillous  space;  P.,  proliferating  villous  epithelium;    V.,  chorionic  villi. 


DEVELOPMENT  OF  THE  PLACENTA  L15 

a  seven-days'  pregnancy  (Fig.  L09).  During  this  period  the  chorionic  villi 
are  devoid  of  blood-vessels,  and  the  ovum  is  uourished  by  osmosis  from  the 
maternal  blood. 

As  pregnancy  advances,  the  blood  supply  of  the  decidua  serotina  be- 
comes more  and  more  abundant,  while  thai  of  the  reflexa  is  diminished; 
as  a  consequence  the  villi  in  contact  with  the  former  are  better  uourished 
and  begin  to  grow  more  luxuriantly  than  those  iipou  the  resl  of  tie-  ovum, 
the  process  thus  Leading  to  the  formation  of  the  chorion  frondosum.  At 
the  same  time  the  villi  covering  the  rest  of  the  ovum  develop  less  rapidly, 
so  that  this  portion  becomes  known  as  the  chorion  lave.  As  the  ovum  in- 
creases  in  size,  the  intervillous  spaces  in  the  chorion  heve  become  smaller 
ami  smaller,  and  by  the  time  the  decidua  reflexa  has  come  iu  contacl  with 
the  vera,  which  happens  at  some  time  in  the  fourth  month  of  pregnancy, 
they  become  obliterated,  and  the  villi  which  project  into  them  undergo 
almost  complete  degeneration.  In  sections  through  the  foetal  membranes 
at  term  (Fig.  loo),  the  chorion  lseve  consists  of  several  layers  of  epithelial 
cells,  which  represent  the  chorionic  epithelium,  and  through  which  are 
scattered,  here  and  there,  round  or  oolong  hyaline  bodies,  in  which  a 
few  spindle-shaped  nuclei  can  he  distinguished.  These  are  the  remains 
of  the  earlier  villi.  At  the  same  time  degenerative  changes  take  place  in 
the  epithelium  of  the  chorion  lseve,  which  result  in  the  formation  of  a 
fibrin-like  material  which  will  be  considered  in  detail  a  little  later. 

On  the  other  hand,  the  villi  of  the  chorion  frondosum  increase  in  size 
and  number,  and  become  vascularized  by  branches  of  the  umbilical  vessels 
of  the  embryo;  so  that  after  the  first  few  weeks  the  foetal  circulation  ex- 
tends to  the  tips  of  the  smallest  villi. 

The  placenta  is  formed  by  the  union  of  the  chorion  frondosum  and  the 
decidua  serotina.  and  therefore  is  composed  of  fcetal  and  maternal  tissues. 
In  the  third  or  fourth  month  of  pregnancy  it  constitutes  a  distinct  struc- 
ture, although  its  site  is  indicated  at  a  much  earlier  period  by  the  in- 
creased thickness  of  the  chorion  at  that  point. 

We  can  probably  best  understand  the  structure  of  the  placenta  by 
studying  sections  through  it  at  the  fourth  month  of  pregnancy,  one  of  which 
is  shown  in  Plate  Y.  Here  we  see  that  the  organ  is  made  up  in  great  part  of 
chorionic  villi,  whose  stroma  presents  a  somewhat  mucoid  appearance,  and 
contains  spindle-  and  star-shaped  connective-tissue  cells,  between  which 
well-developed  arteries,  veins,  and  capillaries  may  be  observed.  At  this 
stage  the  villous  epithelium  is  arranged  in  two  layers — Langhans's  layer 
and  the  syncytium — and  from  the  latter  many  buds  protrude  which,  when 
seen  in  cross  or  tangential  section,  appear  as  giant  cells  lying  free  in  the 
intervillous  spaces. 

In  the  upper  part  of  the  plate  is  the  decidua  serotina.  with  which  some  of 
the  larger  villi— the  fastening  villi— are  connected.  At  their  ends  can 
be  noted  a  marked  proliferation  of  Langhans's  layer,  which  invades  the  un- 
derlying decidua,  giving  rise  to  the  cell  nodes  or  cell  columns,  and  corre- 
sponds to  the  trophoblastic  formation  of  the  early  days  of  pregnancy.  The 
cell  nodes  are  apparently  composed  almost  exclusively  of  Langhans's  cells, 
as  the  svncvtium  does  not  follow  them  down  into  the  depths  of  the  de- 


116  OBSTETRICS 

cidua.  The  spaces  between  the  villi  and  the  decidua,  and  between  the  villi 
themselves,  are  designated  as  the  intervillous  spaces.  These  are  filled  with 
maternal  blood  and  their  walls  are  lined  by  syncytium.  Scattered  through 
them  are  isolated  giant  cells — the  so-called  placental  giant  cells — whose 
origin  we  have  already  considered.  Here  and  there  are  seen  a  few  large 
areas  composed  of  cuboidal  or  polygonal  cells  with  vesicular  nuclei,  which 
frequently  present  marked  signs  of  degeneration.  These  are  the  so-called 
decidual  islands,  and  are  usually  supposed  to  represent  sections  through 
decidual  septa,  which  project  upward  from  the  surface  of  the  decidua 
serotina  towards  the  chorionic  membrane.  But,  as  has  already  been 
pointed  out,  it  is  more  than  probable  that  many  of  them  are  masses  of 
trophoblast,  into  which  the  chorionic  connective  tissue  has  not  grown,  and 
which  therefore  have  not  developed  into  typical  villi. 

At  the  junction  between  the  cell  nodes  and  the  decidual  tissue,  areas 
are  noted  which  stain  deeply  with  eosin,  and  which,  on  closer  examination, 
are  seen  to  be  made  up  of  fibrin,  honeycombed  in  various  directions  by  small 
spaces — the  so-called  canalized  fibrin — which  probably  results  from  the 
degeneration  of  the  deeper  layers  of  the  cell  nodes.  This  is  known  as 
Xitabuelr's  fibrin  layer,  from  the  author  who  first  called  attention  to  its 
presence  in  the  decidua.  Its  existence  has  been  confirmed,  and  its  char- 
acteristics have  been  studied  by  Langhans,  Rohr,  Tussenbroeck,  Ulesko- 
Stroganowa,  and  others,  and  it  is  generally  considered  to  mark  the  border 
line  between  the  foetal  and  maternal  tissues. 

Until  comparatively  recently  the  participation  of  foetal  tissue  in  the 
decidua  serotina  was  not  recognised,  and  when  fcetal  cells  were  found 
beneath  the  chorionic  membrane  they  were  considered  as  being  of  decidual 
origin.  Accordingly,  Winckler  and  other  observers  believed  that  decidual 
tissue  extended  from  the  margins  of  the  decidua  serotina  over  the  whole 
of  the  outer  surface  of  the  chorionic  membrane,  so  that  the  entire  inter- 
villous space  was  included  between  decidual  or  maternal  tissue.  Winckler 
designated  the  superficial  portion  of  the  decidua  as  the  basal,  and  the 
portion  covering  the  chorionic  membrane  as  the  closing  plate  of  the  de- 
cidua. We  have  already  shown  that  the  tissue  in  question  is  composed 
of  fcetal  ectoderm,  and  the  conception  of  decidual  plates  should  therefore 
be  abandoned. 

At  one  point  (Plate  Y)  a  maternal  vessel  is  seen  which,  after  reaching 
the  surface  of  the  decidua,  opens  directly  into  the  intervillous  spaces. 
At  present  it  is  universally  admitted  that  the  blood  in  these  spaces  is 
exclusively  maternal  in  origin. 

The  fcetal  blood  in  the  vessels  of  the  chorionic  villi  at  no  time  gains 
access  to  the  maternal  blood  in  the  intervillous  spaces,  the  two  being 
separated  from  one  another  by  the  double  layer  of  chorionic  epithelium, 
a  portion  of  the  stroma  of  the  villus  and  the  vessel  walls  (Plate  VI). 

Structure  of  Placenta  in  Latter  Half  of  Pregnancy  and  at  Full  Term.— 
Except  in  its  increased  size,  the  placenta  in  the  second  half  of  pregnancy 
differs  but  slightly  from  that  of  the  fourth  month.  Microscopic  sections 
at  this  period,  however,  show  certain  points  of  difference.  These  are  well 
illustrated  in  Fig.  130,  which  represents  a  section  through  a  seven-and-a- 
half-months'  placenta  and  the  adjacent  uterine  wall.     Studying  it  from 


PLATE   VI. 


^.Nv-o^i-gue,^1- 


TERMINAL   CHOKIOXIC   VILLUS,  WITH   INJECTED   VESSELS. 


STRUCTURE  OF  THE  PLACENTA 


117 


within  outward,  we  see  I h&\ 
it  is  composed  of  the  follow- 
ing structures:  amnion,  cho- 
rionic membrane,  villi,  in- 
ten  illous  blood  spaces,  and 
decidua  serotina. 

The  amnion  covers  the 
inner  or  foetal  surface  of  the 
placenta,  and  consists  of  a 
single  layer  of  cuboidal  epi- 
thelium, below  which  comes 
a  layer  of  more  or  less  fibril- 
lar connective  tissue,  con- 
taining no  blood  -  vessels. 
The  chorionic  membrane 
presents  essentially  the  same 
structure  as  in  the  earlier 
months  of  pregnancy,  differ- 
ing only  in  the  presence  of 
a  large  amount  of  canalized 
fibrin  immediately  beneath 
its  epithelium. 

The  great  bulk  of  the  pla- 
centa is  made  up  of  chorionic 
villi,  which  are  much  more 
abundant,  but  at  the  same 
time  considerably  s  m  a  1 1  e  r 
than  at  the  fourth  month. 
Their  stroma,  which  is  made 
itp  of  spindle-shaped  cells, 
is  denser  in  appearance,  is 
occupied  in  great  part  by 
blood  -  vessels,  and  differs 
markedly  from  the  mucoid 
tissue  of  the  earlier  months. 
These  changes  have  already 
been  referred  to.  and  are 
clearly  shown  in  Figs.  116 
and  117. 

The  epithelium  covering 
the  villi  has  also  undergone 
marked  change;  Langhans's 
layer  has  almost  completely 
disappeared  and  only  a  thin 
laver  of  syncytium  remains, 


Fig.  130. — Section  through  Entire 
Thickness  of  Placenta  at  Eighth 
Month.     X  33. 


'-'■■  .         -   Decidua. 

--•'■••  -    *-/- 


2  m 


E-1? 


3&® 


3    space. 


illous 


HSKj 


— Chorionic 
membrane. 
— Amnion. 


Fig.  130. 


^M.H.rtH...',!- 


118  OBSTETRICS 

which  gives  rise  to  fewer  buds  than  previously.  In  many  villi  immediately 
under  the  epithelium,  and  occupying  the  former  position  of  Langhans's 
layer  of  cells,  a  thicker  or  thinner  layer  of  canalized  fibrin  may  be  observed. 
This  was  described  by  Langhans,  and  is  of  constant  occurrence  in  the  latter 
half  of  pregnancy.  It  appears  to  indicate  senile  degeneration  of  the  pla- 
centa. At  the  same  time,  many  of  the  arteries  show  marked  changes  and 
present  all  stages  of  an  obliterating  endarteritis,  to  which,  in  great  part, 
the  formation  of  the  tissue  in  question  should  be  attributed. 

The  superficial  portions  of  the  decidua  at  this  period  are  covered  by 
canalized  fibrin,  which  probably  results  from  coagulation  necrosis  of  the 
cell  nodes  and  columns.  In  the  deeper  layers  numerous  giant  cells  are 
observed,  which  occasionally  extend  into  the  connective-tissue  septa  be- 
tween the  muscle  fibres.  They  are  of  various  shapes,  and  represent  por- 
tions of  syncytium  which  have  wandered  down  into  the  decidua. 

From  the  free  surface  of  the  decidua  numerous  elevations  of  varying 
shapes  and  sizes  extend  upward  for  a  greater  or  less  distance  into  the 
placenta.  They  are  composed  of  cuboidal  or  polygonal  cells,  with  round 
vesicular  nuclei,  and  only  rarely  contain  blood-vessels;  in  many  places 
they  have  undergone  degeneration  and  become  converted  into  canalized 
fibrin.  They  are  usually  described  as  decidual  septa,  but  in  all  proba- 
bility are  derived  from  foetal  ectoderm  or  trophoblast. 

The  entire  space  between  the  chorionic  membrane  and  the  free  surface 
of  the  decidua  serotina  is  designated  as  the  placental  space,  into  which  the 
chorionic  villi  dip,  thereby  subdividing  it  into  myriads  of  irregularly 
shaped  cavities  which  communicate  freely  with  one  another — the  inter- 
villous spaces.  They  are  lined  by  the  syncytium  covering  the  chorionic 
membrane  and  villi,  except  at  those  portions  of  the  decidua  serotina  which 
have  become  converted  into  canalized  fibrin,  and  which  are  only  partially 
covered  by  it.  The  syncytium  is  thinner  than  in  the  earlier  months  of 
pregnancy,  and  under  high  powers  of  the  microscope  its  protoplasm  pre- 
sents a  vacuolated  appearance,  which,  according  to  Marchand,  is  due  to  the 
glycogen  normally  contained  in  it  having  been  dissolved  out  by  the  fluids 
used  in  hardening  the  placenta. 

The  intervillous  spaces  are  at  no  time  lined  by  endothelial  cells,  except 
for  very  short  distances  on  the  surface  of  the  decidua  serotina,  over  which 
the  endothelium  of  maternal  vessels  may  extend  to  a  slight  extent.  It  is 
probable,  however,  that  a  great  part  of  this  tissue  in  reality  represents 
thinned-out  syncytium.  Hence,  it  would  appear  that  the  intervillous  spaces 
are  lined  entirely  by  f cetal  tissue,  and  that  the  maternal  blood,  which  is 
circulating  through  them,  lies  outside  of  the  body  of  the  mother.  The 
maternal  blood  gains  access  to  the  placental  space  by  branches  of  the 
uterine  arteries,  which  pursue  a  convoluted  course  through  the  decidua 
serotina  and,  after  their  walls  have  gradually  become  reduced  to  a  single 
layer  of  endothelium,  open  upon  the  sides  of  the  decidual  septa.  The 
blood  escapes  from  the  intervillous  spaces  through  more  or  less  funnel- 
shaped  openings  upon  the  surface  of  the  decidua,  which  can  be  traced  di- 
rectly into  the  large  venous  sinuses  in  its  depths.  It  is  therefore  apparent 
that  there  is  a  distinct  circulation  through  the  intercommunicating  inter- 


PLATE  VII. 


CORROSION  PREPARATION  OF  MATURE  PLACENTA,  TO   SHOW  FCETAL 

VESSELS.      X  %. 


STRUCTURE  OF  THE   PLACENTA  I  L9 

villous  spaces,  though  it  is  necessarily  more  sluggish  than  elsewhere  In  the 
bodj . 

The  Qature  of  the  intervillous  spans  and  the  question  as  to  whether 
they  contained  maternal  blood  have  given  rise  to  a  greal  deal  of  discussion. 
Vater,  Nbortwyk,  and  William  and  John  Hunter,  In  the  eighteenth  cen- 
tury, expressed  an  affirmative  opinion;  and  the  Las1  two  investigators  con- 
clusively demonstrated  it  by  injection  experiments.  Similar  results  were 
obtained  by  E.  II.  Weber  in  L842.  Bui  this  worls  was  gradualrj  Los1  sighl 
of,  and  a.ll  sorts  of  theories  were  evolved  concerning  the  Qature  and  con- 
tents of  tlic  intervillous  spaces.  Braxton  Hicks,  Ercolani,  and  others  be- 
lieved that  they  did  not  contain  blood,  hui  sonic  substance  derived  from 
the  mucous  membrane  of  the  uterus  which  they  designated  as  uterine  milk. 

Correct  conceptions  as  to  the  nature  of  the  placenta  wnr  finally  estab- 
lished by  the  work  of  Farre,  Turner,  Wakleyer,  Ndtahueh,  Kohr,  Huinin, 
Leopold,  and  others,  who  showed  conclusively  that  the  intervillous  spaces 
contained  maternal  blood,  and  that  vessels  from  the  mother  could  he 
traced  into  them.  This  was  especially  well  demonstrated  by  Waldeyer, 
who.  in  five  pregnant  cadavers,  was  able  to  inject  them  from  the  maternal 
vessels.  Furthermore,  the  recent  work  of  Peters,  Leopold,  and  others,  has 
placed  the  question  beyond  all  doubt. 

Jn  view  of  these  facts,  then,  the  placenta  must  be  regarded  as  a  col- 
lection of  maternal  blood,  included  between  the  chorionic  membrane  and 
the  decidua  serotina,  into  which  the  villi  dip  and  by  which  they  are  sur- 
rounded. Some  idea  of  the  complexity  of  its  vascular  arrangemenl  may 
be  gained  from  Plate  VII,  which  represents  a  corrosion  preparation  of  the 
total  portion  of  a  full-term  placenta,  which  was  injected  through  the  um- 
bilical arteries  and  veins  with  red  and  blue  celloidin.     (Also  see  Plate  VI.) 

Normally  there  is  no  communication  between  the  foetal  blood  contained 
in  the  chorionic  villi  and  the  maternal  blood  in  the  intervillous  spaci  s, 
and  it  would  appear  that  the  transmission  of  substances  from  one  to  the 
other  is  accomplished  partly  by  osmosis  and  partly  by  the  direct  cellular 
activity  of  the  syncytium,  the  process  being  analogous  to  that  which  takes 
place  in  the  tubules  of  the  kidney  and  other  organs.  The  effete  materials 
from  the  foetus  are  carried  by  the  umbilical  arteries  to  the  capillaries  of 
the  terminal  villi,  whence  they  are  transmitted  to  the  maternal  blood  in  the 
manner  just  described.  At  the  same  time  the  oxygen  and  the  materials 
needed  for  the  nutrition  of  the  foetus  are  taken  up  from  the  former  and 
carried  by  the  umbilical  vein  to  the  foetus.  Thus,  in  a  general  way  we 
may  say  that  the  placenta  represents  the  lungs,  stomach,  and  excretory 
organs  of  the  unborn  child. 

Placenta  at  Full  Term. — The  placenta,  as  it  is  cast  off  from  the  uterus 
after  the  birth  of  the  child,  is  a  flattened,  roundish,  or  oval  organ — 15  to 
18  centimetres  in  diameter,  and  2  to  3  centimetres  in  height  at  its  thickest 
part — from  the  margins  of  which  the  membranes  extend.  Ordinarily  its 
weight  is  about  i  of  that  of  the  foetus,  so  that  when  the  latter  is  normally 
developed  the  placenta  weighs  from  500  to  600  grammes. 

It  presents  for  examination  two  surfaces  and  a  margin — the  surface  in 
contact  with  the '  decidua  serotina  being  designated  as  the  maternal  or 


Fig.  131. — Maternal  Surface  of  Mature  Placenta,  showing  Cotyledons  ;  Membranes 

turned  Back.     X  %■ 


Fig.  132. — Fcetal  Surface  of  Mature  Placenta.     X  % 


STRUCTURE  OF  THE  PLACENTA 


121 


outer,  and  thai  directed  towards  the  cavity  of  the  ovum  as  the  total  or 
inner  surface.  The  former  is  covered  by  a  thin  layer  of  decidua  and 
presents  ;i  ragged,  t<>ni  appearance,  being  divided  by  depressions  of 
varying  depth  into  a  number  of  irregularly  shaped  areas,  the  so-called 
cotyledons,  which  vary  considerably  in  number,  as  many  as  twenty  being 
sometimes  observed.  <»n  careful  examination  of  the  decidual  surface,  nu- 
merous  vessels  may   be  seen   which   have   been   torn   through   when   the 


rv 


Fig.  133. — Foetal  Membranes  and  Fterixe  Wall     >    15. 


«..  amnion  :  c.t..  connective  tissue  of  amnion  and  chorion ;  c.e..  chorionic  epithelium ;  c.f..  canalized 
fibrin ;  d.,  decidua :  g..  gland  ;  m..  museularis :  v..  vein :   P.,  atrophic  villus. 


placenta  was  separated.     Thus.  Klein  was  able  to  count  51  arteries  and 
53  veins  in  a  single  specimen. 

The  fcetal  or  inner  surface  presents  a  glistening  appearance,  owing  to 
the  fact  that  it  is  covered  by  amnion,  which,  however,  is  only  slightly  ad- 
herent. When  the  latter  is  removed,  it  leaves  a  coarsely  granular  surface, 
upon  which  the  umbilical  cord  is  usually  inserted  somewhat  eccentrically, 
though  it  may  he  just  at  the  centre  of  the  organ  and  occasionally  near  its 


122 


OBSTETRICS 


*;*    i      '$*         "'.**    -■*.  *^ -■■' 

Fig.  134. — Epithelium  of  Umbilical  Coed.     X  110. 


U.V.- 


margin.     The  various  modes  of  insertion  will  be  considered  when  we  take 
up  the  abnormalities  of  the  placenta. 

The  vessels  composing-  the  umbilical  cord  spread  out  beneath  the 
amnion  and  rapidly  divide,  but  the  main  branches  remain  upon  the 
foetal  surface  of  the  pla- 
centa until  its  margin  is 
reached.  In  many  in- 
stances a  large  vein, 
which  is  usually  known 
as  the  circular  sinus,  ex- 
tends around  a  considera- 
ble portion  of  the  periph- 
ery of  the  placenta,  but 
only  in  very  rare  cases 
completely  encircles  .  the 
organ. 

The  foetal  membranes 
consist  of  the  amnion, 
chorion,  and  a  thin  layer 

of  decidua.     The  amnion,  the  innermost  of  the  membranes,  is  a  thin, 
transparent,  glistening  structure,  which  is  rarely  thicker  than  a  sheet  of 

..  -  writing   paper.      Its   outer 

surface  is  closely  applied 
to  the  chorion,  from  which, 
however,  it  can  usually  be 
separated  without  difficul- 
ty. The  chorion  is  more 
opaque  and  thicker  than 
the  amnion,  though  it  rare- 
ly exceeds  1  millimetre  in 
thickness.  It  represents 
the  chorion  laeve  of  the 
early  months,  and  under 
the  microscope  is  seen  to 
possess  a  number  of  degen- 
erated villi.  Clinging  to 
its  outer  surface  are  a 
few  shreds  of  tissue — the 
portion  of  the  decidua 
which  is  cast  off  after  the 
birth  of  the  child.  Fig. 
133  is  taken  from  a  section 
through  the  foetal  mem- 
branes and  the  uterine  wall 
outside  of  the  placental 
site,    and    gives    a   good   idea    of    their    composition. 

Umbilical  Cord. — The  umbilical  cord,  or  funis,  extends  from  the  navel 
of  the  child  to  the  foetal  surface  of  the  placenta.     Its  exterior  presents  a 


Fig.  135. — Umbilical  Cord,  Fcetal  End.     X  5i. 
U.A.,  umbilical  artery ;   U.S.,  remnant  of  umbilical  stalk ; 
U.  V.,  umbilical  vein. 


UMBILICAL  CORD 


123 


Fig.  136. — Section  through  Umbilical  Coed, 
showing    Stalk    of    Umbilical    Vesii  le. 

x  no. 


dull  white,  moist  appearance,  and  through  ii  shimmer  the  umbilical  vessels 
— two  arteries  and  a  vein.    It  varies  from  1  to  2.5  centimetres  in  diameter, 
and  averages  aboul  55  centimetres  in  length;  though  in  extreme  cases  n 
may  vary  from  0.5  to  L98  cenl  Ime- 
tres.     The  average  Length  of   1,000 
cords,  which  were  measured  at  the 
Johns    Bopkins    Hospital,    was    55 
centimetres,  the  shortest    being    L2 
and  the  longest   100  centimetres. 

The  cord  frequently  presents  a 
twisted  appearance,  the  coiling  usu- 
ally being  from  left  to  right.  As 
the  vessels  arc  usually  longer  than 
the  cord,  they  are  frequently  folded 
upon  themselves,  thus  giving  rise  to 
nodulations  upon  the  surface  which 
are  designated  as  false  knots. 

The  cord  is  covered  by  several 
layers  of  epithelium,  which  is  a 
direct  continuation  of  the  skin  cov- 
ering the  abdomen  of  the  embryo; 

its  interior  is  made  up  of  a  mucoid  connective  tissue — the  so-called  Whar- 
tonian  jelly. 

Microscopic  sections  through  the  foetal  and  placental  ends  of  the  cord 
at  term  present  a  somewhat  different  appearance.  In  the  former,  besides 
the  vessels,  one  usually  sees  two  small,  darkly  staining  areas,  which  under 
higher  magnification  appear  as  small  ducts  lined  by  cuboidal  or  flattened 
epithelial  cells.     One  is  the  remnant  of  the  allantois,  and  the  other  the 

duct  or  stalk  of  the  umbilical  vesicle;  at  the 
placental  end  only  the  latter  is  present. 

In  most  text-books,  it  is  stated  that  the 
cord  is  derived  from  the  allantois,  and  is  cov- 
ered by  a  sheath  of  amnion.  The  researches 
of  His  have  definitely  shown  that  such  is  not 
the  case  in  man,  but  that  the  foetus,  in  the 
earliest  stages  of  pregnancy,  is  connected  with 
the  inner  surface  of  the  chorion  by  a  tolerably 
thick  mass  of  tissue,  only  a  small  portion  of 
which  is  occupied  by  the  allantois.  This 
His  designated  as  the  abdominal  pedicle 
(Bauchstiel),  and  showed  that  it  represents 
merely  an  extension  of  the  caudal  end  of  the 
embryo. 

Fig.  137  represents  a  section  through  the  abdominal  pedicle  of  one  of 
the  early  embryos  studied  by  His,  and  clearly  shows  its  analogy  with  the 
embryonic  area.  The  great  bulk  of  the  structure  is  made  up  of  mesodermic 
tissue  in  which  the  umbilical  vessels  and  the  allantois  are  embedded:  its 
dorsal  surface  is  covered  bv  a  single  laver  of  ectoderm,  showing  at  its 


Fli,.     1ST. — SECTION     THROUGH     Ab- 

dominal  Pedicle  of  2.25-Milll. 
metre  Embryo  (His).     X  50. 
All.    allantois  ;     31. G..    medullary 
groove;    T'.A..  umbilical  artery: 
U.V.,  umbilical  vein. 


124 


OBSTETRICS 


Fig.  138. — Section  through 
Young  Umbilical  Cokd 
(Minot). 

A.,   artery  ;    All.,  allantois  ; 

U.S.,  slalk    of    umbilical 
vesicle ;    V.,  vein. 


middle  a  slight  depression  which  represents  a  continuation  of  the  medul- 
lary groove,  while  arching  over  it  is  the  amnion.  In  its  further  develop- 
ment the  ectodermal  portion  extends  downward  and  inward,  eventually  in- 
closing a  small  portion  of  the  ccelome  in  a  way 
similar  to  that  in  which  the  abdominal  walls  are 
formed  in  the  embryo  itself.  In  this  cavity  the 
stalk  of  the  umbilical  vesicle  or  yolk-sac  is  in- 
cluded. In  the  meantime  the  amnion  is  likewise 
extending  around  the  entire  structure,  but  is  not 
in  contact  with  it;  and  as  the  former  becomes 
more  and  more  distended  by  the  amniotic  fluid,  it 
becomes  farther  and  farther  separated  from  the 
abdominal  pedicle,  or  as  we  may  now  call  it,  the 
umbilical  cord.  Eventually  the  amnion  is  con- 
nected only  with  the  portion  of  the  cord  which  is 
attached  to  the  fcetal  surface  of  the  placenta. 

Fig.  139  represents  a  thirty-days'  embryo  de- 
scribed by  His,  and  gives  a  very  good  idea  of  the 
manner  in  which  the  stalk  of  the  umbilical  vesicle 
becomes  included  within  the  cord. 

Umbilical  Vesicle. — The  yolk-sac,  or,  as  it  be- 
comes later,  the  umbilical  vesicle,  is  a  very  promi- 
nent organ  at  the  beginning  of  pregnancy,  and  is  present  in  all  the 
early  ova  which  have  been  described.  In  its  earliest  stages  it  occupies 
all  of  the  blastodermic  vesicle  which  is  not  taken  up  by  the  embry- 
onic area.  But,  as  the  embryo  develops,  it  becomes  relatively  smaller, 
and,  as  we  have  already  shown,  is  taken  up  in  great  part  to  form  the 
intestinal  canal,  so  that  after 

the  formation  of  the  abdom-  .  \~~  I 

inal  walls  it  protrudes  from 
the  umbilicus  as  a  rounded  sac 
with  a  distinct  stalk.  As  preg- 
nancy advances  the  sac  be- 
comes smaller  and  its  stalk 
longer. 

The  structure  persists 
throughout  pregnancy,  and 
can  nearly  always  be  found 
at  full  term,  when  it  is  repre- 
sented by  a  small  oval  sac,  3 
to  5  millimetres  in  diameter, 
which  usually  lies  on  the  fcetal 
surface  of  the  placenta,  be- 
tween the  chorion  and  amnion, 
but  occasionally  in  the  mem-- 

branes  just  beyond  the  placental  margin.  It  is  connected  with  the  um- 
bilical cord  by  a  fine  pedicle,  which,  as  has  been  already  shown,  may  be 
seen  in  sections  through  the  cord  at  term.     Schultze,  in  1861,  was  able  to 


Fig.  139. — Stalk  of  Umbilical  Vesicle  being  in- 
cluded in  the  Umbilical  Coed  (His). 


UMBILICAL   VTESICLE  L25 

demonstrate  the  umbilical  vesicle  in  L46  out  of  150  mature  placenta; 
examined. 

The  intra-abdominal  portion  of  the  duel  of  the  umbilical  vesicle,  which 
extends  from  the  umbilicus  to  the  intestine,  usually  atrophies  and  disap- 
pears, l >ii t  occasionally  i1  remains  patent,  forming  what  is  known  as 
Meckel's  diverticulum,  which  may  play  an  importanl  pathological  pari  in 
later  life. 

In  animals  whose  ova  possess  a  large  amount  of  yolk,  the  umbilical 
vesicle  is  the  main  source  of  nutrition  for  the  embryo;  but  in  those  of 
women  its  significance  is  not  so  clear,  since  the  proportion  of  yolk  is  ex- 
ceedingly  small.  It  must,  however,  play  an  important  part  in  the  economy 
of  the  embryo,  as  it  develops  a  considerable  circulation,  and,  as  Selenka 
has  shown,  forms  numerous  crypts  from  its  entodennal  lining.  As  yet, 
however,  we  are  unacquainted  with  its  functions. 

LITERATURE 

Bumm.    Zur  Kenntniss  der  Utero-placentar-gefasse.    Arehiv  f.  Gyn.,  xxxvii,  1-15.  1890. 
Ueber  die  Entwickelung  dor  raiitterlichen  Blutkreislaufes  in  der  menschl.  Placenta. 

Arehiv  f.  Gyn..  xliii,  181-195,  1893. 
Dai.rymple.     Medico-chir.  Transactions,  xxv,  21,  1842  (quoted  by  Waldeyer). 
Duval.     Le  placenta  des  carnassiers.     Annales  de  Gyn.  et  d'Obst.,  xlv,  167-182,  1896. 
Exgelmaxx.     The  Mucous  Membrane  of  the  Uterus,  etc.     Amer.  Join-.  Obst.,  viii,  30-87. 

1875. 
Ercolaxi.     Delia  struttura  anat.  della  caduca  uterina,  etc.     Bologna,  1874. 

Quoted  by  Waldeyer,  p.  5. 
Fakre.     Uterus  and  its  Appendages.     Todd's  Cyclopaedia  of  Anat.  and  Physiol.,  Parts 

XLIX  and  L. 
Fehlixg.     Ueber  die  physiologische  Bedeutung  des  Fruchtwassers.     Arehiv  f.  Gyn..  xiv 

221-244,  1879. 
Fraxkel,  L.     Vergleichende  Untersuchungen  des  Uterus-  und  Chorion-epithels.    Arehiv 

f.  Gyn..  lv,  269-316,  1898. 
vox  Fraxqce.     Cervix  und  unteres  Uterinsegment,  Stuttgart,  1897. 
Friedlaxder,     Physiol,  anat.  Untersuchungen  fiber  den  Uterus.     Leipzig,  1870. 
Frommel     Verb.  d.  deutschen  Gesellschaft  f.  Gyn.,  i,  306,  1886. 
Gerhard.     Ueber  das  sogenannte   Syncytioiua  malignum.     Zeitschr.  f.  Geb.  u.  Gyn.. 

xxxvii,  480-518.  1897. 
IIegar.      Beitrage   zur   Pathologie   des   Eies,   etc.      IVlonatsschr.   f.   Geburtskunde.  xxi. 

Supplement  Heft,  1-66.  1863. 
TTexxtg.    Die  weissen  Blutkorperchen  und  die  Deciduazellen.    Arehiv  f.  Gyn.,  vi.  508. 

509,  1874. 
Herff.     Beitrage   zur   Lehre-von   der   Placenta  und  von  den    miitterlichen   Eihiillen. 

Zeitschr.  f.  Geb.  u.  Gyn.,  xxxv,  268-297  and  325-372.  1896. 
Heukelom.     Ueber  die  menschliche  Placentation.    Arch.  f.  Anat.  u.  Physiol.,  Anat.  Abth., 

1898.  1-36. 
Hicks.     The  Anatomy  of  the  Human  Placenta,     Trans.  London  Obst.  Soc.  xiv.  149-189,. 

1873. 
His.     Bauchstiel  und  Nabelstrang,  Anatomie  menschlicher  Embryonen.  iii.  222-226.  1885. 
Die  Umschliessung  der  menschl.  Frucht  wahrend  der  fiiihesten  Zeiten  der  Schwanger- 

schaft.     Arch.  f.  Anat.  u.  Physiol..  Anat.  Abth..  1897,  399-430. 
Hubrecht.     The  Placentation  of  Erinaceus  Europaeus,  with  remarks  on  the  Phylogeny 

of  the  Placenta.     Quart.  Jour,  of  Microscop.  Science,  xxx,  1889. 


126  OBSTETRICS 

Hubrecht.     Die  Rolle  des  embryonalen  Trophoblasts  bei  der  Placentation.     Centralbl.  f. 

Gyn.,  1897,  1206. 
Hunter,  John.     Observations  on  Certain  Parts  of  the  Animal  Economy.     London,  1778. 
Hunter,  Wm.     Anatomy  of  the  Human  Gravid  Uterus.     London,  1774. 
Hyrtl.     See  Kollmann. 
Kastchenko.     Das   menschliche  Chorionepithel  und   dessen  Rolle  bei  der  Histogenese 

der  Placenta.     Arch,  f.  Anat.  u.  Physiol.,  Anat.  Abth.,  1885. 
Kinoshita.      Ueber  grosszellige  decidua-ahnliche  Wucherungen  auf   dem   Peritoneum. 

Monatsschr.  f.  Geb.  u.  Gyn.,  viii,  500-509,  1898. 
Klein.     Entwickelung  und  Ruckbildung  der  Decidua.     Zeitschr.  f.  Geb.  u.  Gyn.,  xxii. 

247-295,  1891. 
Kollmann.     Lehrbuch  der  Entvvickelungsgeschichte  des  Menschen.     Jena,  1898. 
Kossmann.     Zur  Histologie  der  Chorionzotten  des  Menschen.     Leuckhart's  Festschrift, 

1892. 
Zur  Histologie   der  Extrauterinschwangerschaft,  nebst   Bemerkungen   iiber   ein   sehr 

junges  mit  der  Decidua  gelostes  Ei.     Zeitschr.  f.  Geb.  u.  Gyn.,  xxvii,  266-286,  1893. 
Kundrat  u.  Engelmann.     Untersuchungen  iiber  die  Uterusschleimhaut.    Strieker's  med. 

Jahrb.,  1873. 
Langhans.    Untersuchungen  iiber  die  menschliche  Placenta.    Arch.  f.  Anat.  u.  Entwicke- 

lungsgesch.,  Leipzig,  1877,  188-276. 
Ueber  die  Zellschicht  des  menschliehen  Chorions.     Beitrage  zur  Anat.  und  Embryologie, 

(Henle's  Festgabe),  Bonn,  1882. 
Leopold.     Studien  iiber  die  Uterusschleimhaut,  etc.     Berlin,  1878. 

Ueber  den  Bau  der  Placenta.     Verh.  d.  deutschen  Gesell.  1  Gyn.,  iii,  257, 1890. 
Uterus  u.  Kind.     Leipzig,  1897. 
Leopold,  Marchesi,  u.  Bott.    Zur  Entwickelung  und  der  Bau  der  menschliehen  Placenta. 

Arch.  f.  Gyn.,  lix,  516-544,  1899. 
Lindenthal.     Ueber  Decidua  ovarii.    Monatsschr.  f.  G.  u.  G.,  xiii,  707-723, 1901. 
De  Loos.      Das  Wachstum  der  menschliehen    Chorionzotten.      D.  I.,  Freiburg  in   B., 

1897. 
Marchand.     Ueber  die  sogenannten  "  decidualen  "  Geschwulste.     Monatsschr.  f.  Geb.  u. 

Gyn.,  i,  419-513,  1895. 
Beitrage  zur  Kenntniss  der  Placentarbildung.     Marburg,  1898. 
Merttens.      Beitrage   zur   normalen    u.   path.   Anatomie    der    menschliehen    Placenta. 

Zeitschr.  f.  Geb.  u.  Gyn.,  xxx,  1-97,  1894. 
Minot.     Uterus  and  Embryo.     Jour,  of  Morphology,  ii,  No.  3,  1889. 

Human  Embryology.     New  York,  1892. 
Nitabuch.     Beitrage  zur  Kenntniss  der  menschliehen  Placenta.     D.  I.,  Bern,  1887. 
Noortwyk.     Quoted  from  Waldeyer. 
Opitz.     Vergleich  der  Placentarbildung  bei  Meerschweinchen,  etc.,  mit  derjenigen  beim 

Menschen.     Zeitschr.  f.  Geb.  u.  Gyn.,  xli,  120-144  and  153-173,  1899. 
Overlach.     Die  pseudomenst.  Mucosa  uteri.     D.  I.,  Munchen,  1885. 
Peters.     Ueber  die  Einbettung  des  menschliehen  Eies.     Wien,  1899. 
Reichert.     Beschreibung  einer  friihzeitigen    menschliehen    Frucht.     Abhandlungen   d. 

konigl.  Akacl.  d.  Wissenschaften,  Berlin.  1873. 
Rohr.    Die  Beziehungen  der  mutterlichen  Gefasse  zu  den  intervillosen  Raumen  der  reifen 

Placenta,  speciell  zur  Thrombose  derselben  ("  weisser  Infarct ").     D.  I.,  Bern,  1889. 
Ruge.     Ueber   die  menschliche  Placenta.     Zeitschr.   f.  Geb.    u.   Gyn.,   xxxix,   550-588, 

1898. 
Schmorl.     Ueber  grosszellige  (decidua-ahnliche)  Wucherungen  auf  dem  Peritoneum  u. 

den  Ovarien  bei  intrauteriner  Schwangerschaft.      Monatsschr.  f.  Geb.  u.  Gyn.,  v,  46, 

1897. 
Schultze.     Das  Nabelblaschen  ein  constantes  Gebilde  in  der  Nachgeburt  des  ausgetra- 

genen  Kindes.     Leipzig,  1861. 


DEVELOPMENT  OP  THE  OVUM  127 

M.i.i.NKA.    Studien  ilber  Entwickelungsgeschichte  der  Thiere,  Beft  5,  Wiesbaden,  1891. 

Menschen-Affen,  11,  Wiesbaden,  L899. 
Sharkey.      English   translation  of   Mttller's   Handbuch  der  Physiologic,  according  to 

Schroeder's  Lehrbuch,  XIII.  Aufl.,  L899. 
Sobotta.     I"i'    Befruchtung  und  Purchang  des  Eies  der  Maus.    Archiv  f.  mikro.  Anat., 

L895,  \lv.  L5-93. 
mii.     Beobachtungen  an  einer  raenschl.  Keimscheibe  mil   offener  Medullarrinne,  etc. 

Archiv  f.  Anat.  u.  Phys.,  Anat.  Abth.,  1899,  L59-176. 
rTeue  Beobachtungen   iib'er  sehr  friihe   Entwickelungsstufen  des  menschlichen   Eies 

Arch.  f.  Anat.  u.  Physiol.,  Anat.  Abth.,  1896,  1-30. 
Tukxkk.    Observations  on    the   Structure  of  the   Human   Placenta.    Jour.  Anal,  ami 

Physiol.,  vii,  120,  1873;  also  xi.  1877. 
Tussenbroeck.     Die  Decidua  uterina  bei  ektopischer  Sehwangersehaft,  etc.     Yirchow's 

Archiv,  exxxiii,  207-230,  1893. 
Ulesko-Stroganowa.     Beitriige  zur  Lehre  vom  inikros.  Ban.  der  Placenta.     Monatsschr. 

f.  Geb.  u.  Gyn.,  iii,  207,  1896. 
Vateb.  Quoted  from  Waldeyer. 
Waldeyer.     Bemerkungen  liber  den  Bau  der  Menscheu-  und  Affen-Placenta.    Archiv  f. 

mikros.  Anat.,  xxxv,  1-52,  1890. 
Weber,     Zusatze  vom  Bau  und  den  Verrichtungen  der  Geschlechtsorgane.    Abh.  der  kgl. 

sachsischen  Akademie,  1846. 
Webster,     The  Changes  in  the  Uterine  Mucosa  during  Pregnancy  and  in  the  Attached 

Foetal  Structures.     Amer.  Gyn.  and  Obst.  Journal,  x,  168-264  and  535-662,  1897. 
Human  Placentation.     Chicago,  1901. 
vox  Weiss.     Zur  Kasuistik  der  Placenta  praevia  centralis.     Centralbl.  f.  Gyn.,  641-649, 

1897. 
Wixcklek.     Textur,  Structur  und  Zellleben  in  den  Adnexen  des  menschlichen  Eies. 

Jena,  1870. 


CHAPTER  V 
THE    FCETUS 

The  Foetus  in  the  Various  Months  of  Pregnancy. — It  is  a  matter  of 
considerable  importance  that  the  physician  be  able  to  tell  approximately 
the  age  of  embryos  and  prematurely  born  children,  and  we  shall  there- 
fore give  a  short  description  of  the  foetus  at  its  various  periods  of  devel- 
opment. 

The  average  duration  of  pregnancy,  from  the  commencementof  the 
last  menstrual  flow  to  the  onset  oi'laboiir,  is  two  hundred  ancTeigJityday^. 
or  ten  lunar  months,  though  a  considerable  number  of  children  are  born 
shortly  before  or  after  the  expiration  of  that  period. 

The  following  details  concerning  the  development  of  the  unborn  child 
are  taken  in  great  part  from  His,  who  distinguished  three  periods  in  its 
evolution.  Thus,  during  the  first  two  weeks^  of  pregnancy  the  product 
of  conception  is  designated  as  the  ovum;  frojn  the  third  to  the  fifth  week 
— the  period  during  which  the  various  organs  are  developed  and  a  definite 
form  is  assumed — it  is  known  as  the  embryo:  after  _the  fifth  week  it  be- 
comes the  foejus^^ 

First  Two  Weeks. — The  earliest  human  ova  with  which  we  are  ac- 
quainted were  described  by  Peters,  Leopold,  Reichert,  and  Spee.     These 


Fig.  140. 


Fig.  141.  Fig.  142.  Fig.  143.  Fig.  144. 

Figs.  140-145. — Early  Embryos  described  by  His. 


were  vesicular  structures  whose  most  prominent  feature  was  the  chorion, 
to  one  side  of  which  was  attached  the  future  embryo,  so  small  a  body  that 
its  component  parts  could  be  distinguished  only  with  the  aid  of  the  micro- 
scope. In  each  of  these  ova  the  embryonic  area  was  covered  by  a  well- 
developed  amnion,  and  the  great  bulk  of  the  structure  consisted  of  the 
yolk-sac.  Spee's  ovum  presented  the  earliest  stages  in  the  formation  of 
the  embryo  itself — namely,  the  primitive  streak.  Figs.  140  to  145  repre- 
sent early  ova  described  by  His. 

Third  Week. — The  embryonal  period  begins  with  the  third  week,  in 
the  early  part  of  which  can  be  detected  the  beginning  formation  of  the 
128 


TUK  V< KITS    IX    THE    VARIOUS    MONTHS 


120 


medullary  groove  and  canal,  soon  to  be  followed  by  the  appearance  of  the 
head-ioWs.  At  this  stage  of  development  the  abdominal  pedicle  is  seeo 
coming  off  from  the  tail  end  of  the  embryo,  and  lying  almosl  in  the  same 
axis  with  it.  The  embryo  is  concave  on  its  dorsal  surface,  and  is  made  up 
in  great  part  of  the  yolk-sac. 

A  little  later,  the  formation  of  the  double  heart  may  be  noted;  while, 
in  the  latter  part  of  the  week  the  ccrcbraj  and  optic  vesicles  appear,  as 
well  as  the  viscejuL^irdms  and  clefts"  The  yolk-sac  becomes  more  and 
more  constricted,  and  is  connected  with  the  ventral  surface  of  the  embryo 
by  a  broad  pedicle.  At  the  very  end  of  the  third  week  (about  the  twenty- 
first  day)  the  limbs  make  their  appearance  as  small  buds  upon  the  sur- 
face of  the  embryo. 

Fourth  Week. — This  week  is  characterized  by  a  great  increase  in  the 


size  of  the  embryo,  which  becomes  markedly  flexed  upon  its  ventral  sm 


Fig.  146. 


Fig.  147. 


Fiji.  148. 


Fig.  149. 


Figs.   146-149. — Embryos  from  Fourth  and  Fifth  Weeks  (His).     X  2. 


face,  so  that  its  head  and  tail  ends  come  almost  in  contact.  The  rudi- 
ments of  the  eves,  ears,  and  nose  now  make  their  appearance,  and  the 
umbilical  vesicle  becomes  still  more  pedunculated.  At  the  end  of  the 
first  lunar  month  the  embryo  measures  from  7.5  to  10  millimetres  (0.3  to 
0.-1  inch)  in  length. 

Second  Month. — In  the  first  half  of  the  second  month  the  human  em- 
bryo does  not  differ  essentially  in  appearance  from  that  of  other  animals. 
It  is  still  markedly  bent  on  itself,  and  the  visceral  clefts  and  arches  are 
the  most  prominent  characteristics  of  its  cephalic  region,  while  the  ex- 
tremities are  in  a  very  rudimentary  condition.  In  the  latter  part  of  the 
month,  owing  to  the  development  of  the  brain,  the  head  becomes  con- 
siderably larger,  and  assumes  a  certain  resemblance  to  that  of  a  human 
being.  At  the  same  time  the  nose,  mouth,  and  ears  become  less  prominent 
and  the  extremities  more  developed,  so  that  it  can  be  seen  that  they  are 
made  up  of  three  portions.  The  external  genitalia  also  make  their  ap- 
pearance in  the  latter  part  of  this  month,  and  at  ffs  end  the  foetus  has 
attained  a  length  of  2.5  centimetres  (1  inch). 

Third  Month. — At  the  end  of  this*" month  the  entire  product  of  con- 
ception is  about  as  large  as  a  gooseys  egg,  .and  the  embryo  measures  from 
7  to  9  centimetres  in  length.  Centres  of  ossification  have  appeared  in  most 
of  the  hones;  the  fingers  ancTToes  becomiTalffei7entiated  and  are   sup- 


130 


OBSTETRICS 


plied  with  nails;  the  external  genitalia  are  beginning  to  show  definite 
signs  of  sex. 

Fourth  Month. — By  the  end  of  the  fourth  month  the  foetus  is  from  10 
to  17  centimetres  long,  and  weighs  about  120  grammes.  An  examination  of 
the  external  genital  organs  will  now  definitely  reveal  the  sex. 

Fifth  Month. — The  foetus  varies  from  18  to  27  centimetres  in  length, 
and  weighs  about  280  grammes.     Its  skin  has  become  less  transparent,  a 


Fig.  150.  Fig.  151.  Fig.  152. 

Figs.  150-152. — Embryos  fkom  Second  Month  (His).     X  2. 


downy  covering  is  seen  over  its  entire  body,  while  a  certain  amount  of 
typical  hair  has  made  its  appearance  on  the  head. 

Sixth  Month. — At  the  end  of  the  sixth  month  the  foetus  varies  from 
28  to  34  centimetres  in  length,  and  weighs  about  634  grammes.  The  skin 
presents  a  markedly  wrinkled  appearance,  and  fat  begins  to  be  deposited 
beneath  it;  the  head  is  still  comparatively  quite  large.  A  foetus  born  at 
this  period  will  attempt  to  breathe  and  move  its  limbs,  but  always  perishes 
within  a  short  time. 

Seventh  Month. — The  length  during  this  month  varies  from  35  to  38_ 
centimetres,  and  the  foetus  attains  a  weight  of  over  1,200  grammes.  The 
entire  body  is  very  thin,  the  skin  is  reddish  and  covered  with  vernix 
caseosa.  The  pupillary  membrane  has  just  disappeared  from  the  eyes.  A 
foetus  born  at  this  period  moves  its  limbs  quite  energetically  and  cries 
with  a  weak  voice;  but,  as  a  rule,  it  cannot  be  raised,  even  with  the 
most  expert  care,  although  an  occasional  successful  case  is  found  in  the 
records. 

It  is  generally  believed  among  the  laity  that  a  child  born  at  the  end 
of  the  seventh  month  has  a  better  chance  of  living  than  when  it  comes 
into  the  world  four  weeks  later.     This  idea  is  a  remnant  of  the  old  Hip- 


THE   FOETUS   IN   THE  VARIOUS   MONTHS 


i:;i 


pocratic  doctrine  and  is  absolutely  erroneous,  as  the  more  developed  the 
child  the  greater  arc  its  chances  for  life. 

Eighth  Month. — At  the  end  of  the  eighth  i ith  the  foetus  has  attained 

a  Length  of  42.5  centimetres,  and  a  weighi  of  aboui  L,900  grammes.  The 
surface  of  the  skin  is  still  red  and  wrinkled,  and  the  child  resembles  an 
old  man  in  appearance.  Children  born  at  this  period  may  Live  if  properly 
cared  for,  though  their  chances  are  not  yery  promising. 

Ninth  Month. — At  the  end  of  the  ninth  month  the  foetus  is  46.75  centi- 
metres long,  and  weighs  about  2,500  grammes.  Owing  to  the  presence  of 
considerable  fat,  the  body  has  become  more  rotund  ,-ind  the  face  has  Losl 
its  previous  wrinkled  appearance.  Children  born  at  this  time  have  a  very 
fair  chance  of  life  if  properly  cared  for. 

Tenth  Month. —  Full  term  is  reached  at  the  end  of  this  month.  The 
I'o'tus  is  now  fully  developed,  and  presents  the  appearances  which  we  shall 
consider  in  detail  when  we  describe  the  new-born  child. 

According  to  Ahlfeld,  the  average  weight  and  length  of  the  fcetus  in 
the  last  four  months  of  its  development  are  as  follows: 


Week. 

Weight. 

Length. 

27th 

1.142  grammes. 

1.635 

1.576 

1.868 

1,872 

2.107 

2,084 

2,424 

2,753 

2,806 

2,878 

3,016 

3,321 

3,168 

28th 

29th   

40.4 

39  6          " 

30th 

31st 

42 

43  7          " 

32d 

43  4 

33d 

43  88        " 

34th 

46  07        " 

35th 

47  03 

36th 

48  3 

37th 

48  3 

38th 

49  9 

39th 

50  6          " 

40th 

50  5          •' 

These  figures  possess  only  an  approximate  value,  and  generally  speak- 
ing the  length  affords  a  more  accurate  criterion  of  the  age  of  a  child  than 
its  weight.  Haase  has  suggested  a  very  simple  method  of  determining  the 
size  of  the  embryo  at  its  various  periods  of  development.  According  to 
him,  the  length  in  centimetres  may  be  roughly  approximated  during  the 
first  five  months  by  scmaring  the  number  of  the  month  to  which  the  preg- 
nancy lias  advanced:  in  the  second  half  of  pregnancy,  by  multiplying  the 
month  by  5,  as  is  shown  in  the  following  table: 

At  the  end  of  the  first  month lxl.  1  centimetre. 

"  "  second  month 2x2.  4  centimetres. 

"  "  third  month 3x3.  9 

"             "  "  fourth  month 4x4.  16 

"  "  fifth  month 5x5.  25 

"  "  sixth  month 6x5.  30 

"             "  "  seventh  month 7x5,  35           " 

"             "  "  eighth  month 8x5.  40           " 

"  "  ninth  month 9x5.  45           " 

"            "  "  tenth  month 10x5.  50 


132  OBSTETRICS 

The  Child  at  Full  Term.— The  average  child  at  full  term  is  ^^to^ol 
centimetres  (20  to  21  inches)  long,  and  •\veighs^3J250gTammes  (7_pjmnds). 
Tliellkin'is"  smooth  and  polished  in  appearance,  and  shows  no  lanugo,  ex- 
cept occasionally  about  the  shoulders.  Over  the  entire  surface  is  spread  a 
whitish,  greasjT  material,  the  rej-jilx  casM>sa,  which  is  a  mixture  of  ^gpi- 
Hielial  cells,  lanugqjiairs,  and_t]ig  secretion  ofjdie  sebaceou^^lands.  The 
head  is  usually  covered  by  darkish  hairs  2  to  3  centimetres  in  length,  and 
the  cartilages  of  the  nose  and  ears  are  well  developed.  The  fingers  and 
toes  possess  well-developed  nails,  which  project  beyond  their  tijjs.  In 
male  children  the  testicles  are  usually  found  within  thescrotuni;  in 
girls  the  labia  majora  are  "well  developed  and  are  in  contact  with  one  an- 
other, and  usually  conceal  the  rest  of  the  genitalia.  The  bp-oe^  of  the 
head  are  well  ossified,  and  are  in  close  contact  at  the  various  sutures. 
%t  aufopsy  a  centreoi  ossification,  0.5  centimetre  in  diameter,  is  found 
in  the  lower  epiphysis  of  the  femur.  This  was  first  described  by  Blecard, 
in  1826,  as  a  diagnostic  sign  of  maturity.  It  is  not  infallible,  however,  as 
Hartmann  has  shown  that  it  was  absent  in  12  out  of  102  full-term  chil- 
dren which  he  examined.  Xo  one  of  these  conditions  affords  indisputable 
proof  of  the  maturity  of  a  child,  but  when  the  majority  of  them  are  present 
the  evidence  becomes  fairly  convincing. 

Soon  after  its  birth,  and  occasionally  just  after  the  head  emerges  from 
the  vulva,  and  before  the  expulsion  of  the  entire  body,  the  child  makes 
inspiratory  movements  and  begins  to  cry  loudly.  It  moves  its  extremities 
freely,  and  after  a  short  time  passes  urine  and  meconium. 

Xegro  babies  at  birth  differ  somewhat  in  appearance  from  white  chil- 
dren, but  not  so  markedly  as  one  would  expect.  Their  skin  presents  a 
dusky,  bluish-red  hue,  but  does  not  at  all  suggest  the  darker  colour  which 
it  will  assume  in  the  course  of  a  few  weeks.  Where  there  is  a  considerable 
admixture  of  white  blood,  the  dusky  hue  may  be  entirely  absent,  and  the 
only  evidence  of  negro  ancestry  will  be  found  in  an  increased  pigmentation 
about  the  external  genitalia. 

Weight  of  the  New-born. — The  average  infant  at  birth  weighs  about 
3,250  grammes  (?  pounds),  boys  being  usually  100  grammes  (3  ounces) 
heavier  than  girls.  Marked  variations  are  frequently  observed,  which  are 
dependent  upon  the  race  and  size  of  the  parents,  the  number  of  children 
which  the  mother  has  borne,  her  mode  of  life,  and  her  nutrition  and  gen- 
eral condition  during  the  later  months  of  pregnancy.  In  500  full-term 
white  children  born  at  the  Johns  Hopkins  Hospital,  the  average  weight 
was  3,409  grammes  (7  pounds  5  ounces),  the  smallest  child  weighing  2,180 
grammes  (4  pounds  11  ounces)  and  the  largest  4,553  grammes  (9  pounds 
12  ounces). 

It  appears  that  coloured  children  weigh  considerably  less  than  white,  a 
fact  that,  in  large  cities,  at  least,  is  indicative  of  the  physical  degenera- 
tion which  characterizes  the  race.  Five  hundred  full-term  coloured  chil- 
dren born  at  the  Johns  Hopkins  Hospital  averaged  3,023  grammes  (6 
pounds  8  ounces)  in  weight,  a  difference  of  386  grammes  (13  ounces)  in 
favour  of  the  white  race. 

Similar  but  less  marked  differences  may  be  observed  in  the  different 


WEIGHT  OF  THE  PCETUS  L33 

countries  and  even  in  various  portions  of  the  same  country.  Thus 
Schroeder  found  thai  the  children  born  in  Bonn  averaged  71  grammes 
(-.",  ounces)  less  in  weighl  than  those  observed  03   Eecker  in  Munich. 

Perfectly  healthy  full-term  children  may  vary  from  2,300  to  5,000 
grammes  (5  to  L0|  pounds)  in  weight.  They  rarely  exceed  the  latter 
figure,  although  it  is  not  unusual  to  hear  of  children  weighing  15.  L6,  and 
even  20  pounds  at  birth.  The  majority  of  these  cases,  however,  must  be 
regarded  as  apocryphal,  and  careful  inquiry  will  usually  show  that  the 
weight  lias  been  only  roughly  estimated  by  lifting  the  child  in  the  hand, 
and  not  based  upon  accurate  determination.  Hecker  in  1,096  cases  found 
only  2  children  that  weighed  over  5,000  grammes,  and  Winckel  only  5 
in  30,500  deliveries.  According  to  Ludwig,  out  of  15,166  children  born 
in  Chrobak's  clinic  in  Vienna,  only  1  weighed  5,300  grammes  (ll£ 
pounds),  and  Varnier  states  that  in  seven  years,  at  the  Baudeloeque  Clinic 
in  Paris,  there  were  only  6  children  that  exceeded  5,000  grammes  at 
birth,  the  largest  weighing  6.150  grammes  (13  pounds  3  ounces). 

Out  of  nearly  3,000  children  delivered  under  my  supervision,  the 
largest  weighed  5,833  grammes,  or  12  pounds  8  ounces;  though  several  of 
my  friends  have  met  with  babies  which  were  considerably  heavier.  Du- 
bois, in  1897,  collected  from  the  literature  28  cases  in  which  the  child 
weighed  5,600  grammes  (12  pounds)  or  more  at  birth,  and  stated  that 
the  heaviest  children  on  record  were  reported  by  Ortega,  Bachel  and  Xeu- 
mer  and  Beech,  and  weighed  respectively  11,300  (24  pounds  3  ounces). 
11. "250  (2d  pounds  2  ounces),  and  10,T50  grammes  (23  pounds  12  ounces). 
Ortega's  child  was  TO  centimetres  (28  inches)  long,  and  Beech's  76  centi- 
metres (30  inches).  Ludwig,  a  few  years  ago,  reported  a  case  in  which  he 
was  obliged  to  perform  Csesarean  section,  after  craniotomy  and  amputa- 
tion of  the  extremities,  in  order  to  deliver  a  child  weighing  7,700  grammes 
(16  pounds  8  ounces).  But  in  spite  of  these  exertional  cases,  one  should 
be  extremely  sceptical  in  accepting  reports  concerning  jdienomenally  heavy 
children,  unless  one  is  convinced  that  the  reporter  is  a  truthful  person  and 
has  weighed  the  child  upon  an  accurate  balance. 

On  the  other  hand,  children  are  frequently  met  with  under  3,250 
grammes  (7  pounds)  in  weight,  and  it  is  not  unusual  to  see  healthy  full- 
term  babies  weighing  from  2,333  to  2,800  grammes  (5  to  6  pounds).  Any 
weight  below  5  pounds,  in  the  case  of  an  infant  born  at  term,  should  always 
lead  one  to  suspect  some  disease  on  the  part  of  the  mother  or  foetus,  as^ 
nephritis  or  syphilis. 

Generally  speaking,  premature  children  weighing  less  than  1,500 
grammes  (3  pounds  3  ounces)  have  practically  no  chance  of  life,  though 
exceptional  cases  have  been  reported  in  which  such  infants  have  done 
well.  Piering.  in  a  recent  article,  reports  raising  a  premature  child 
that  weighed  only  1.120  grammes  at  birth,  and  mentions  cases  under 
the  charge  of  Bitter.  Rodman,  and  D'Outrepont  in  which  children 
weighing  only  717.  710.  and  750  grammes  respectively  were  successfully 
reared. 

The  size  of  the  foetus  increases  with  the  age  of  the  mother  up  to  the 
twenty-eigKth  or  thirtieth  veaj,  if  pregnancies  have  not  followed  in  too 


134 


OBSTETRICS 


rapid  succession;  the  children  of  succeeding  pregnancies  usually  follow  the 
same  rule. 

The  size  of  the  foetus  is  also  dependent.,  to  a  considerable  extent,  upon 
that  of  the  parents,  especially  the  father;  and  in  many  instances  its  head 
closely  resembles  that  of  the  father  in  shape. 

The  social  condition  of  the  mother  and  the  comforts  by  which  she  is 
surrounded  also  exert  a  marked  influence  upon  the  child's  weight,  heavier 
children  being  more  common  in  the  upper  walks  of  life.  Thus,  on 
looking  over  the  records  of  my  private  cases,  which  are  almost  exclusively 
among  the  well-to-do  classes,  I  found  that  133  healthy  full-term  children, 
which  I  had  weighed  upon  the  same  pair  of  scales,  averaged  3,795  grammes 
(8  pounds  2  ounces)  in  weight,  as  compared  with  3,409  and  3,023  grammes 
for  the  white  and  coloured  children  in  hospital  practice — a  difference  of 
386  and  772  grammes,  respectively.  The  heaviest  child  weighed  5,833 
grammes  (12  pounds  8  ounces),  and  the  lightest  2,536  grammes  (5  pounds 
8  ounces).  Eleven  weighed  4,666  grammes  (10  pounds),  and  15  weighed 
3,266  grammes  (7  pounds)  or  less,  leaving  107  between  the  two  limits. 

Pinard  and  Bachimont,  from  a  study  of  4,445  cases  observed  in  the 
Baudelocque  Clinic,  have  lately  arrived  at  more  or  less  similar  conclusions. 
They  found  that  the  children  of  women  who  had  lived  in  the  hospital  for 
three  months  prior  to  confinement  averaged  50.0  grammes .  (1  pound  2 
ounces)  heavier  than  those  of  patients  who  had  entered  the  hospital  just 


Fig.  153.— Child's  Head  at  Term.     X  %■     f  American  Text-Book.) 


before  or  during  labour.  They  consider  that  this  difference  is  due  to  the 
better  nourishment  of  the  former  class  of  patients,  and  to  the  absence  of 
hard  work  and  the  consequent  tendency  to  premature  labour.  Fuchs,  of 
Halle,  obtained  approximately  the  same  results. 

Provided  the  pelvis  is  normal,  it  is  unusual  for  children  weighing  less 
than  5,000  grammes  (10  pounds)  to  cause  difficult  labour  simply  from  their 


THE   1 1 1  :\  I  >  OF  THE    FCETUS 


135 


size,  since  Varnier  has  shown  that  the  diameters  of  ihc  head  do  not  increase 
in  the  same  ratio  aa  thcj>,  eight  of  the  child. 

The  Head  of  the  Child. — From  an  ohstetrical  point  of  view  the  bead 
of  the  child  i<  ii-  mosl   important  pari,  as  the  essential  feature  of  labour 
is  a  process  of  adaptation  between  it  and  the  various  portions  of  the  pelvis 
through  which  it  passes.    An  ac- 
curate knowledge  of  its  charac-  Occiput 
teristics  and   size   is  therefore  of 
capital  importance. 

Only  a  comparatively  small 
part  of  the  head  of  the  child  at 
term  is  represented  by  the  face. 
the  rot  being  composed  of  the 
ii rm.  hard  skull,  which  is  made 
up  of  two  frontal,  two  parietal, 
two  temporal  bones,  the  upper 
portion  of  the  occipital,  and  the 
wings  of  the  sphenoid.  These 
bony  portions  are  not  firmly 
united  together,  but  are  sepa- 
rated from  one  another  by  spaces 
tilled  with  membrane — the  su- 
tures. Of  these  the  most  impor- 
tant are  the  frontal,  between  the 
two  frontal  bones;  the  sagittal, 
between  the  two  parietal  bones; 
the  coronal,  between  the  frontal 
and  parietal  bones;  and  the  lamh- 
doid  suture,  between  the  poste- 
rior margins  of  the  parietal  bones 
and    the    upper    margin    of    the 

occipital  bone.  All  of  these  sutures  can  be  felt  during  labour;  whereas  the 
temporal  suture,  which  is  situated  on  either  side  between  the  inferior  mar- 
gin of  the  parietal  and  the  upper  margin  of  the  temporal  bones,  is  covered 
by  -oft  parts  and  cannot  be  felt  on  the  living  child. 

Where  several  sutures  meet  together  an  irregular  space  is  formed, 
which  is  closed  by  a  membrane  and  designated  as  a  fontanelle.  We  usually 
distinguish  four  such  structures:  the  greater  and  lesser,  and  the  two  tem- 
poral fontanelles.  The  greater  or  anterior  fontanelle  is  a  lozenge-shaped 
space  situated  at  the  junction  of  the  sagittal  and  the  coronal  sutures.  The 
lesser  or  posterior  fontanelle  is  represented  by  a  small  triangular  area  at  the 
intersection  of  the  sagittal  and  lambdoid  sutures.  These  are  readily  felt 
during  labour,  and  their  recognition  gives  important  information  concern- 
ing the  position  and  presentation  of  the  child.  The  temporal  or  Gasserian 
fontanelles.  which  are  situated  at  the  junction  of  the  lambdoid  and  temporal 
sutures,  cannot  be  felt  on  vaginal  examination. 

Arnold  Lea  has  lately  directed  attention  to  the  occasional  presence  of 
what  he  designates  as  the  sagittal  fontanelle,  which  is  a  lozenge-shaped 


JTig.  154. — Child's  Head  at  Term.     X  %■ 
(American  Text-Book. 


136 


OBSTETRICS 


space  found  in  the  sagittal  suture  at  a  point  about  half-way  between  the 
greater  and  lesser  fontanelles.  He  considers  that  it  results  from  faulty 
ossification  of  the  parietal  bones,  and  states  that  it  occurs  quite  frequently — 
in  22  out  of  500  foetal  skulls  which  he  examined  (4.4  per  cent).  I  have 
met  with  a  similar  structure  in  only  two  instances,  and  in  one  it  gave  rise 
to  a  serious  error  in  diagnosis.     Since  that  time  I  have  examined  several 

hundred  foetal  heads  just  after  birth, 
but  have  not  encountered  other  exam- 
ples of  the  abnormality,  so  that  it  would 
seem  probable  that  Lea's  experience  was 
very  excej^tional. 

To  aid  us  in  forming  definite  ideas 
concerning  the  shape  and  size  of  the 
foetal  head,  it  is  customary  to  measure 
certain  diameters  and  circumferences. 
The  diameters  most  frequently  used  are : 
(1)  the  fronto-occipital,  which  follows 
a  line  extending  from  the  root  of  the 
nose  to  the  most  prominent  portion  of 
the  occipital  bone;  (2)  the  biparietal, 
which  represents  the  greatest  transverse 
diameter  of  the  head,  and  usually  ex- 
tends from  one  parietal  boss  to  the 
other;  (3)  the  bitemporal,  which  repre- 
sents the  greatest  distance  between  the 
two  temporal  sutures;  (4)  the  mento- 
occipital,  from  the  chin  to  the  most  prominent  jjortion  of  the  occiput;  and 
(5)  the  suboccipito-bregmatic,  which  follows  a  line  drawn  from  the  middle 
of  the  large  fontanelle  to  the  under  surface  of  the  occipital  bone,  just  where 
it  joins  the  neck.  For  convenience  the  various  diameters  are  frequently 
designated  by  initials,  which,  with  their  several  average  measurements,  are 
given  in  the  following  table: 

Fronto-occipital,  F.  0 11 .  75  centimetres. 

Biparietal,   B.  P 9.25  " 

Bitemporal,  B.  T 8  " 

Mento-occipital,  M.  0 13.5  " 

Suboccipito-bregmatic,  S.  0.  B 9.5  " 


Fig.  155. — Head  at  Term,  showing  Small, 
Sagittal,    axd    Large     Fontanelles. 


The  greatest  circumference  of  the  head,  which  corresponds  to  the  plane 
of  the  fronto-occipital  diameter,  is  34.5  centimetres,  while  the  least  cir- 
cumference, corresponding  to  the  plane  of  the  suboccipito-bregmatic  di- 
ameter, is  32  centimetres.  The  figures  just  given  are  based  upon  the  aver- 
age measurements  of  a  large  number  of  heads  just  after  birth,  individual 
variations  being  frequently  encountered.  As  a  rule,  boys  have  somewhat 
larger  heads  than  girls,  and  the  children  of  multiparas  than  those  of 
primiparse. 

A  certain  amount  of -motility  exists  at  the  sutures  between  the  various 
bones  composing  the  skull.     This  may  vary  within  relatively  wide  limits 


PHYSIOLOGY   OF   THE    FOETUS 


L37 


in  differeni  individuals,  so  thai  beads  which  afford  the  same  diameters  on 
actual  measuremenl  nol  infrequently  differ  markedly  in  the  obstacle  which 
they  offer  to  labour,  as  the  bones  of  one  may  be  soft,  compressible,  and 
readily  displaced,  while  those  of  another  arc  firmly  and  densely  ossified 
and  admitting  <>l'  bu1  little  motility,  the  former  being  readily  moulded  to 
the  genital  canal,  while  the  latter  is  incapable  of  reduction  in  size. 

Physiology  of  the  Foetus. — Our  knowledge  concerning  the  physiology 
of  ilu.'  foetus  has  been  markedly  enriched  during  recent  years;  neverth 
when  compared  with  that  of  the  adult,  it  offers  many  points  concerning 
which  we  are  but  slightly  informed  or  profoundly  ignorant. 

Nutrition  of  the  Foetus. — Owing  to  the  small  amount  of  yolk  contained 
in  the  human  ovum,  the  growth  of  the  fcetus  is  almost  entirely  dependent 
upon  the  amount  of  nutritive  material  which  it  obtains  from  its  mother. 

During  the  first  few  months  of  pregnancy,  as  Fell  ling  first  pointed  out. 
the  embryo  consists  almost  entirely  of  water,  and  it  is  during  this  period 
that  it  grows  most  rapidly.  In  the  later  months  of  pregnancy,  when  more 
solids  are  heing  added,  the  increase  in  size  becomes  gradually  slower. 
Fehling's  conclusions  were  confirmed  by  Michel,  who  analyzed  foetuses  at 
various  periods  of  their  development.  Some  of  his  results  are  shown  in  the 
following  table: 


Water. 


At2|  months.. 
3d  to  4th  month 

7th  month 84.75 

At  term 69.16 


93.82  percent. 
89. 95 


Albuminoids. 


4.89  per  cent. 

7.05 
10.04        " 
13.96 


Salts. 


Trace. 
1 . 729  per  cent. 
2.487        " 
3.373 


Fats. 


Trace. 
.0379  per  cent. 
1.823 
11.75 


It  is  therefore  apparent  that,  as  the  fcetus  increases  in  age,  it  contains 
relatively  less  water  and  a  markedly  increased  epiantity  of  albuminoid  ma- 
terials, salts,  and  fats. 

During  the  first  few  weeks  after  the  implantation  of  the  ovum  upon 
the  uterine  mucosa  its  nutrition  is  entirely  dependent  upon  osmosis. 
From  the  end./>fj:he  first  week  it  is  surrounded  by  deeidua,  and  between  it 
and  the  chorion  are  developett  the  intervillous  blood  spaces  which  are  filled 
with  maternal  blood.  At  this  period  the  chorionic  villi  are  devoid  of  ves- 
sels, and  the  only  way  in  which  nutritive  material  can  be  taken  up  from 
the  maternal  blood,  by  which  these  are  surrounded,  is  bv  osmosis. 

In  the  third  week  of  pregnancy  the  omphalo-mesenteric  vessels  make  ,  < 
their  appearance  upon  the  surface  of  the  umbilical  vesicle,  and  whatever  | 
nutritive  materials  the  latter  may  contain  are  conveyed  to  the  embryo  by 
them.     During  the  fourth  week  branches  of  the  umbilical  vessels  appear  ' 
in  the  _qh  or  ionic  villi,  and  from  this  time  on  the  greater  part  of  the  nutri-  ' 
tion  of  the  foetus  is  received  from  the  maternal  blood,  which  in  the  earlier^." 
weeks  of  pregnancy  surrounds  the  entire  ovum,  but  soon  becomes  limited 
to  the  placental  site. 

The  Foetal  Circulation. — Owing  to  the  fact  that  the  materials  needed 
for  the  nutrition  of  the  fcetus  are  brought  to  it  by  the  umbilical  vein,  the 
fcetal  circulation  differs  materiallv  from  that  of  the  adult  (Plate  YTII). 


138  OBSTETRICS 

The  blood  is  purified  and  laden  with  nutritive  material  in  the  placenta,  and 
is  then  carried  to  the  foetus  through  the  umbilical  vein,  which,  after  pene- 
trating the  abdominal  wall,  divides  into  two  branches.  Of  these  the 
smaller  unites  with  the  portal  vein,  the  blood  from  which  circulates 
through  the  liver  and  then  gains  access  to  the  inferior  vena  cava  through 
the  hepatic  vein.  The  other,  the  larger  branch,  which  is  designated  as  the 
ductus  venosus,  empties  directly  into  the  vena  cava.  The  contents  of  the 
vena  cava  above  the  hepatic  vein,  therefore,  consist  of  a  mixture  of  arterial 
blood  from  the  placenta  and  venous  blood  returning  from  the  lower  ex- 
tremities of  the  foetus.  This  is  carried  into  the  right  auricle,  and  owing 
to  the  intervention  of  the  Eustachian  valve  is  directed  through  the  fora- 
men ovale  into  the  left  auricle,  whence  it  passes  into  the  left  ventricle,, 
which  forces  it  into  the  aorta.  The  greater  part  of  this  blood  makes  its 
way  into  the  vessels  which  supply  the  head  and  neck,  while  only  a  small 
portion  of  it  passes  by  way  of  the  arch  of  the  aorta  to  nourish  the  lower 
portions  of  the  body. 

The  blood  which  is  returned  from  the  head  and  upper  extremities  by 
way  of  the  superior  vena  cava  is  poured  into  the  right  auricle,  and  cross- 
ing the  current  from  the  inferior  vena  cava  passes  into  the  right  ventricle, 
whence  it  is  forced  into  the  pulmonary  arteries.  But  so  long  as  the  lungs  do- 
not  function,  only  a  small  portion  of  this  blood  gains  access  to  them,  the 
greater  part  of  it  passing  through  the  ductus  arteriosus  to  the  arch  of  the 
aorta,  and  being  then  carried  to  the  rest  of  the  body  of  the  embryo. 

The  bloodx which  has  gained  access  to  the  aorta  directly  from  the  left 
and  also  from  the  right  ventricle,  through  the  ductus  arteriosus,  is  pro- 
pelled down  the  aorta  and  given  off  to  the  various  organs  according  to 
their  needs;  but  the  bulk  of  it  enters  the  internal  iliac  and  hypogastric 
arteries — the  latter  after  passing  the  umbilicus  being  designated  as  the 
umbilical  arteries — and  through  them  gains  access  to  the  placenta. 

From  the  foregoing  description  it  is  apparent  that  the  blood  circulating 
in  the  foetus  is  at  no  time  strictly  arterial  or  strictly  venous,  but  that  the 
content  of  the  inferior  vena  cava  is  far  purer  than  that  of  the  aorta. 

The  distinctive  features  of  the  foetal  circulation  are  connected  with 
the  ductus  venosus  and  arteriosus,  the  foramen  ovale,  the  hypogastric 
arteries,  and  the  umbilical  cord.  After  birth  these  structures  undergo- 
marked  changes.  As  soon  as  the  child  is  born  and  begins  to  breathe,  the 
pulmonary  circulation  becomes  established.  As  a  result,  a  much  greater 
quantity  of  blood  is  pumped  by  the  right  ventricle  into  the  pulmonary 
arteries,  while  a  lessened  amount  passes  through  the  ductus  arteriosus. 
Moreover,  as  soon  as  the  circulation  in  the  cord  is  abolished,  the  umbilical 
vein  becomes  functionless,  and  a  diminished  quantity  of  blood  is  returned 
to  the  right  auricle  by  the  inferior  vena  cava.  This  change  leads  to  a 
diminution  in  the  tension  in  the  right  auricle,  while  that  in  the  left  side 
oTthe  "heart  is  increased,  bringing  about  the  closure  of  the  valve-likp  foia- 
men  ovale. 

As  the  circulation  through  the  umbilical  arteries  ceases  almost  im- 
mediately after  the  pulmonary  circulation  is  established,  the  function  of 
the  hypogastric  arteries  is  rendered  useless,  and  their  distal  ends  rapidly 


PLATE    VIII. 


"-  PULMO'.'- 


F0- 


FLETAL   CIECULATIOX. 


PHYSIOLOGY   OF   THE   FCETUS  L39 

undergo  atrophy  and  obliteration,  which  is  usually  complete  t_hrccj>r  1'otn- 
days  after  birth.  The  ductus  venosus  and  umbilical  srein  also  become 
uccludcil  during  the  first  wivk,  whereas  the  closure  of  the  ductus  arteriosus 
is  more  gradual,  and  frequently  its  opening  does  uo1  become  impervious 
until  several  weeks  after  liirtli.  J'ei-inaiieiit  closure  of  the  foramen  ovale 
does  not  Tieeur  tor  some  time,  and  not  rarely  months  elapse  before  it  is 
completed.  Occasionally  it  remains  more  or  less  patent,  and  circulatory 
disturbances  of  greater  or  less  gravity  resull  from  its  persistence. 

Transmission  of  Substances  through  the  Placenta. — As  was  shown  when 
considering  the  structure  of  the  placenta,  there  is  no  direct  communication 
between  the  vessels  of  the  chorionic  villi  and  the  intervillous  blood  spaces. 
In  the  first  half  of  pregnancy  foetal  and  maternal  blood  are  separated  from 
one  another  by  the  syncytium.  Langhans's  layer  of  cells,  a  thicker  or 
tlunner  leaflet  jrf  the  stroma  of  the  villus,  and  the  walls  of  the  f  total 
ca}udlaries.  while  in  the  second  halt  Langhansjs  layer  gradually  dis- 
appears. 

The  independence  of  the  two  circulations  is  readily  demonstrated  on 
examining  the  contents  of  the  foetal  vessels  and  the  intervillous  spaces. 
In  the  former  Imtqp  numbers  of  nucleated  red  corpuscles  are  found,  which 
are  never  present  in  the  latter.  In  order  that  substances  may  pass  from 
the  mother  to  the  foetus,  or  in  the  reverse  direction,  it  is  necessary  for 
them  to  traverse  the  layers  of  tissue  which  we  have  just  mentioned.  It 
would  appear  that  .gases  and  substances  in  solution  pass  by  osmosis  directly 
from  the  maternal  blood  to  the  vessels  of  the  chorionic  villi,  and  vice  versa. 
but  that  formed  substances  must  undergo  certain  changes  in  the  chorionic 
epithelium  before  they  can  be  transmitted. 

The  transmission  of  gaseous  substances  has  been  definitely  demon- 
strated both  by  clinical  observation  and  experimental  work.  Comparison 
of  the  blood  in  the  umbilical  vein  and  arteries,  respectively,  shows  that 
the  former  is  lighter  in  colour,  indicating  that  it  is  richer  in  oxygen  than 
the  latter.  This  fact  has  also  been  demonstrated  experimentally  by  Zwei- 
fel,  who  showed  that  the  blood  in  the  umbilical  vein,  when  examined  by 
means  of  the  spectroscope,  contained  oxyhemoglobin.  Again.  Cohnstein 
and  Zuntz  have  demonstrated  that  the  bloocToi  the  umbilical  vein  in  the 
sheep  is  richer  in  oxygen  and  poorer  in  carbon  dioxide  than  that  con- 
tained in  the  umbilical  arteries.  Zweifel  has  also  shown  that  chloroform 
administered  to  the  mother  is  rapidly  transmitted  to  the  foetus. 

The  increase  in  the  size  of  the  foetus  affords  conclusive  evidence  that 
materials  in  solution  must  pass  from  the  maternal  to  the  foetal  circulation, 
and  this  has  been  demonstrated  experimentally  for  a  number  of  substances. 
The  first  work  of  this  character  we  owe  to  Mayer,  who  in  181?  proved  the 
passage  of  cyanide  of  potassium.  Since  then  conclusive  evidence  of  such 
transmission  has  been  adduced  for  iodide  and  ferrocvanide  of  potassium, 
salicylic  acid,  corrosive  sublimate,  methylene  blue7  and  many  other  sub~- 
stances.  " 

Kronig  and  Fiith  in  1901  investigated  the  molecular  concentration  of 
the  foetal  and  maternal  blood  by  determining  their  freezing  points.  They 
found  that  both  fluids  froze  at  the  same  temperature,  a  fact  which  indi- 


140  OBSTETRICS 

cates  that  they  possess  the  same  osmotic  pressure,  and  that  osmosis  can 
occur  equally  readily  in  either  direction.  ' 

The^evuTence  concerning  the  passage  of  formed  substances  through  the 
placenta  is  conflicting,  but  the  general  belief  is  that  such  does  not  occur, 
unless  the  material  has  first  undergone  marked  changes  under  the  influ- 
ence of  the  chorionic  epithelium,  or  the  placenta  presents  lesions.  The 
occurrence  of  intra-uterine  small-pox  -was  urged  by  John  Hunter  and  many 
subsequent  observers  as  proof  in  support  of  the  affirmative  view.  Formerly 
it  was  not  infrequent  for  mothers  who  suffered  from  small-pox  during 
pregnancy  to  give  birth  to  children  bearing  marks  of  the  disease,  and  one 
of  the  most  celebrated  cases  of  this  character  was  that  of  Mauriceau,  the 
well-known  obstetrician  of  the  seventeenth  century,  who  was  born  pock- 
marked. The  significance  of  this  occurrence,  however,  is  by  no  means 
clear,  inasmuch  as  we  are  not  as  yet  acquainted  with  the  materies  morbi 
concerned. 

It  has  been  already  pointed  out  that  the  nucleated  red  corpuscles  of 
the  foetus  do  not  gain  access  to  the  intervillous  spaces,  and  Sanger  has 
shown  that  maternal  blood-cells  do  not  enter  the  chorionic  vessels,  by 
demonstrating  in  a  case  of  pernicious  leucaemia  that  the  leucocytes  of  the 
mother  did  not  pass  to  the  foetus;  and  the  same  fact  holds  good  in  malaria, 
as  there  is  no  evidence  that  in  the  case  of  a  pregnant  woman  suffering  from 
this  disease  the  specific  parasites  can  pass  from  the  maternal  to  the  foetal 
blood.  A  large  amount  of  experimental  work  has  been  done  with  such  sub- 
stances as  powdered  cinnabar,  India-ink,  and  sulphindigodate  of  sodium,  the 
earlier  investigators  having  reported  positive,  and  the  more  recent  investi- 
gators negative,  results.  It  appears  probable  that  the  former  were  due  to 
injuries  sustained  by  the  placenta  during  the  manipulation. 

The  passage  of  bacteria  from  the  mother  to  the  foetus  has  of  late  years 
been  a  fruitful  field  for  experimentation,  and  it  is  now  generally  admitted 
that  the  transmission  occurs  only  in  exceptional  instances.  Lubarsch,  in 
a  recent  article,  has  shown  that  the  organisms  of  anthrax,  pneumonia, 
typhoid  fever,  relapsing  fever,  and  the  various  infections  due  to  pyogenic 
organisms,  may  be  transmitted  now  and  again,  but  regards  such  an  occur- 
rence as  exceptional. 

This  is  particularly  well  shown  in  tuberculosis,  and  so  far  as  the  litera- 
ture shows,  out  of  the  large  number  of  tuberculous  women  who  are  deliv- 
ered every  year,  only  18  have  given  birth  to  children  or  placentae  which 
gave  evidence  of  the  disease.  Birch-Hirschfeld,  Schmorl,  and  Lehmann 
have  described  tuberculosis  of  the  foetal  portion  of  the  placenta,  and  Sar- 
wey  recognised  a  case  of  congenital  tuberculosis  in  a  deformed  foetus.  But 
in  none  of  the  placentae  from  tuberculous  women  which  I  have  examined 
have  I  been  able  to  find  the  slightest  trace  of  tuberculosis  in  the  foetal  por- 
tion, even  when  the  decidua  was  affected  by  the  disease. 

The  same  applies  to  typhoid  fever,  though  it  would  appear  that  in 
this  disease  the  transmission  of  organisms  occurs  more  frequently  than  in 
tuberculosis.  Speier,  in  1897,  found  the  specific  bacilli  in  the  organs  of  a 
foetus  whose  mother  was  suffering  with  typhoid  fever,  and  collected  11 
similar  cases  from  the  literature.    "We  have  lately  observed  an  instance  of 


THE    AMNIOTIC   FLU  ID  141 

the  sal  lie  character  a1  1 1  m  ■  John-  I  lopkins  Hospital,  which  has  been  reported 
by  l\  W.  Lynch. 

From  the  evidence  before  us  it  would  appear  that  so  long  as  tin-  pla- 
centa is  norma]  and  the  epithelium  covering1  its  villi  inta<l;  the  transmis- 
sion ol*  disease  genus  does  not  occur,  but  that  when  lesions  of  the  placenta 
are  present  it  is  quite  possible.  It  remains  to  he  decided,  however, 
whether  the  lesions  that  wnr  demonstrated  had  existed  prior  to  the  dis- 
ease, or  had  resulted  from  toxines  produced  by  the  bacteria  circulating  in 
the  intervillous  spaces. 

The  transmission  of  materials  from  the  fcetus  to  the  mother  has  also 
been  experimentally  demonstrated  for  animals.  Thus  Savory  and  Gus- 
serow  showed,  by  injecting  strychnine  into  embryos  still  within  the  uterus, 
that  the  mother  died  within  a  short  time  from  strychnine  poisoning.  Simi- 
lar results  were  also  obtained  by  Preyer  with  hydrocyanic  acid. 

The  Nature  and  Functions  of  the  Amniotic  Fluid. — In  addition  to  the 
materials  received  from  the  placenta,  it  is  generally  believed  that  the  fcetus 
obtains  a  great  part  of  the  fluid  necessary  for  its  development  from  that 
contained  in  the  amniotic  sac.  Spiegelberg,  Ahlfekl,  Zweifel  and  others 
have  demonstrated  that  considerable  quantities  of  it,  are  swallowed,  inas- 
much as  they  found  lanugo  hairs,  epidermic  cells,  etc.,  in  the  stomach  and 
intestines  of  the  fcetus.  Ahlfekl  believes  that  the  amniotic  fluid  is  swal- 
lowed in  such  large  quantities  that  even  the  small  amount  of  albumin  which 
it  contains  is  of  some  benefit  in  the  nutrition  of  the  fcetus;  but  this  point  is 
very  doubtful. 

According  to  Hoppe-Seyler,  the  amniotic  fluid  is  clear,  alkaline  in  reac- 
tion,Jiaving  a  specific  gravity  of  1.006  to  1.008,  and  consisting  ofD8.48  per 
cent  water,  0.19  per  cent  albuminoid  material,  0.556  per  cent  soluble  inor- 
ganic salts,  0.8  per  cent  extractives,  and  0.024:  per  cent  insoluble  organic 
salts. 

It  is  generally  admitted  that  it  represents  in  great  part  a  transuda^.  1/ 
tion  from  the  maternal  vessels,  but  many  authorities  consider  that  a  por- 
tion of  it  is  derived  from  the  urinary  secretion  of  the  fcetus.  The  solution 
of  the  question  in  the  case  of  human  beings  presents  very  serious-  diffi- 
culties; though  Doderlein  has  conclusively  shown  that  in  the  calf  the  fcetal 
kidneys  function  during  the  latter  part  of  pregnancy,  as  in  this  animal 
the  urinary  excretions  are  passed  into  the  allantoic  vesicle  and  do  not  min- 
gle with  the  contents  of  the  amnion.  But  in  the  human  fcetus.  which  does 
not  possess  a  vesicular  allantois,  it  is  evident  that,  if  the  kidneys  secrete, 
the  iirine  must  be  passed  into  the  amniotic  cavity,  and  this  problem  has 
not  yet  been  definitely  solved.  The  question  has  been  answered  in  the 
affirmative  by  Schroeder,  Xagel.  and  others,  their  conclusions  being  based 
in  great  part  upon  the  formation  of  retention  cysts  in  embryos  which 
presented  some  abnormality  in  the  lower  portion  of  the  urinary  tract. 
Chemical  analysis  of  the  amniotic  fluid,  however,  shows  that  it  contains 
very  small  quantities  of  urea,  and  indicates  that  the  fcetal  urine,  if  secreted 
at  all.  differs  markedly  from  that  of  extra -uterine  life. 

The   experiments   of   Schaller,   in   1899,   have   rendered   it   extremely 
doubtful  whether  the  fcetal  kidneys  function  at  all.    This  observer  availed 
10 


; 


142  OBSTETRICS 

himself  of  the  well-known  fact  that  the  administration  of  phloridzin  gives 
rise  to  a  transient  diabetes,  which  results  from  the  action  of  the  drug  upon 
the  renal  epithelium,  and  not  from  changes  produced  in  the  blood.  He 
showed  that  after  the  drug  had  been  injected  into  the  mother  its  pres- 
ence could  readily  be  demonstrated  in  the  tissues  of  the  foetus,  while  the 
amniotic  fluid  rarely  contained  traces  of  sugar,  which  should  have  been 
present  in  large  quantity  had  the  foetal  kidneys  functioned. 

In  addition  to  supplying  water  to  the  tissues,  the  amniotic  fluid  plays 
an  important  part  by  surrounding~~tne  IcetuTwitli  a  medium  of  constant 
temperature,  which  serves  to  prevent  loss  of  heat  while  at  the  same  time 
affording  a  protection  ao-ainst  sudden  shocks  from  without.  It  also  sub- 
serves an  important  function  by  preventing  the  formation  of  adhesions 
between  the  foetus  and  the  walls  of  the  amniotic  sac,  which,  when  they 
occur,  often  give  rise  to  serious  deformities  to  be  considered  later. 

Respiratory  and  Digestive  Functions. — It  would  appear  that  the  foetus 
in  utero  requires  a  relatively  small  quantity  of  oxygen  to  support  life,  so 
there  is  but  little  tissue  waste.  Again,  the  fact  that  it  is  surrounded  by 
amniotic  fluid  makes  it  necessary  for  the  foetus  to  produce  but  little 
warmth,  as  only  a  small  amount  of  energy  is  expended  during  its  restricted 
movements.  Its  need  of  oxygen,  however,  is  demonstrated  by  the  rapid 
occurrence  of  death,  with  symptoms  of  asphyxia,  whenever  the  circulation 
of  the  umbilical  cord  is  interfered  with  even  for  a  short  time. 

It  has  been  demonstrated  that  the  foetus  actually  produces  warmth, 
as  Wurster  showed  that  its  temperature  exceeded  that  of  the  interior  of 
the  uterus  by  0.5°  C.  or  0.9°  F.  Vicarelli  has  lately  arrived  at  a  similar 
conclusion,  although  he  puts  the  excess  at  only  0.2°  C.  or  0.36°  F. 

Very  little  is  known  concerning  the  functions  of  the  intestinal  tract 
of  the  foetus,  though  it  has  been  demonstrated  that  the  stomach  contains 
pepsin  jtnchrennin  after  thefifth  month,  their  presence  indicating  a  certain 
amount  of  glandular  activity.  The  large  amount  of  blood  which  circulates 
through  the  liver  would  go  to  show  that  this  organ  serves  some  important  ' 
purpose,  and  the  formation  of  bile  is  conclusively  demonstrated  by  the  pres- 
ence of  biliary  materials  in  the  meconium. 

While  the  foetus  remains  in  the  uterus  its  movements  are  restricted 
within  narrow  limits,  though  such  undoubtedly  occur,  being  felt  by  the 
mother  as  "  life  "  from  the  middle  of  pregnancy,  and  at  a  little  later  period 
by  the  physician  when  he  places  his  hand  upon  the  abdomen.  Ahlfeld 
demonstrated,  by  the  use  of  the  sphygmograph,  that  the  foetus  makes  very 
rapid  superficial  movements — at  the  rate  of  sixty  to  the  minute — which  he 
considered  represented  an  abortive  type  of  respiration;  but  his  conclusions 
have  not  been  accepted  by  other  observers. 

Sex  of  the  New-born  Child. — Statistics  show  that  more  boys  are  born 
than  girls,  the  proportion,  according  to  the  figures  given  by  Eauber,  being 
106  to  100.  Ahlfeld  has  pointed  out  that  this  ratio  is  still  further  in- 
creased in  elderly  primipara?;  for  when  the  first  child  is  born  between  the 
thirtieth  and  fortieth  years,  the  proportion  is  120-130  to  100,  which  in- 
creases to  130-140  to  i00  between  the  fortieth  and  fiftieth  years. . 

Various  theories  have  been  advanced  from  time  to  time  in  explanation 


SEX   OP  THE   FOETUS  14:; 

of  this  fact,  bu1  Done  of  them  are  altogether  satisfactory.  Those  who  are 
interested  in  the  subjecl  are  referred  t<>  the  monograph  of  Ranber  for  de- 
tailed information. 

At  presenl  we  are  almost  absolutely  ignorant  concerning  the  causation 
of  sex,  though  certain  observers  are  inclined  to  suppose  that  the  di 
mining  factor  must  be  soughl  for  in  the  ovum.  Probability  is  lent  to  this 
view  by  the  fact  that  twins  derived  from  the  same  ovum  an-  always  of  the 
same__se>U  but  when  each  is  derived  from  a  separate  ovum,  the  sex  may  or 
may  not  be  the  same.  We  do  riot  know,  however,  whether  the  determination 
di'  sex  resides  in  the  ovum  before  fertilization,  or  takes  place  soon  aft<  r  it. 
though  it  must  occur  at  a  very  early  period,  since  the  researches  of  Clark 
and  others  have  shown  that  embryos  do  not  present  an  indifferent  stage  of 
sexual  development,  as  was  formerly  believed;  for  examination  of  the  in- 
ternal generative  organs  enables  one  to  differentiate  the  sex  at  a  much 
earlier  period  than  was  formerly  believed  possible. 

Several  years  ago  Schenk  startled  the  world  by  stating  that  sex 
could  be  determined  at  will,  as  it  was  entirely  dependent  upon  the  con- 
dition of  nutrition  of  the  mother,  and  could  therefore  be  influenced 
by  appropriate  dietetic  treatment.  Further  investigation,  however,  has 
shown  that  his  conclusions  were  visionary. 


LITERATURE 

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523-55  7.  1877. 
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Beschafti.^ung  der  Mutter.     D.I..  Halle.  1899. 
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miitterliehen  und  kindlichen  Blute.     Monatsschr.  f.  Geb.  u.  Gyn..  xiii.  39-54.  1901. 
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Soc.,  xl,  263-270.  1898. 


144  OBSTETRICS 

Lehmann.     Ueber  einen  Pall  von  Tuberculose  der  Placenta.    Deutsche  med.  Wochenschr., 

No.  9,  1893.     Also  Berliner  klin.  Wochenschr.,  1894,  601. 
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Gyn.,  1896,  64,  65. 
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Hopkins  Hospital  Reports,  1902,  x,  203-322. 
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trique,  v,  252-261,  1900. 
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131-148,  1889. 
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Gyn.,  x,  303-311,  1899. 
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f.  Gyn.,  xliii,  162-180,  1893. 
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Physiologie  des  Fotus.     Lehrbuch  der  Geb.,  XIII.  Aufl.,  75,  1899. 
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235-257,  1877. 


PHYSIOLOGY    OF    PREGNANCY 

CHAPTER  VI 

CHANGES  IN  TEE  MATERNAL   ORGANISM  RESULTING  FROM 

PREGNANCY 


Uterus. — The  maternal  organism  reacts  to  a  greater  or  lesser  extent 
under  the  influence  of  pregnancy,  but  naturally  the  most  characteristic 
changes  are  observed  in  the  generative  tract,  and  especially  in  the  uterus, 
which  undergoes  a  very  marked  increase  in  size.  Thus,  it  is  converted  from 
a  small,  almost  solid  organ,  6.5  centimetres  long,  into  a  thin-walled,  mus- 
cular sae,  capable  of  containmgfhe  foetus,  placenta,  and  a  large  quantity  of 
amniotic  fluid,  and  at  the  end  of  pregnancy  is  about  36  centimetres  long, 
25  centimetres  wide,  and  24  centimetres  deep.  Krause  estimated  that  its 
capacity  is  increased  519  times.  A  corresponding  increase  in  weight  is 
also  observed,  the  ute- 
rus at  full  term  weigh- 
ing in  the  neighbour- 
hood of  1,000  grammes 
(2  pounds),  as  compared 
with  30  grammes  (1 
ounce)  in  the  virginal 
condition. 

This  enlargement  is 
due  principally  to  the 
hypertrophy  of  pre-ex- 
istmg_^2^cl^cells,  but 
partly  also  to  tlie  for- 
mation of  new  ones  dur- 
ing the  earlier  months 
of  pregnancy.  The  fully 
developed  muscle  fibres 
are  from  2  to  7  times 
wider  and  from  7  to  11 
times  longer  than  those 
observed  in  the  non- 
pregnant uterus,  measuring  0.009  to  0.014  X  0.2  to  0.52  millimetre  in  the 
former,  as  compared  with  0.005  X  0.05  to  0.07  millimetre  in  the  latter.  Ac- 
cording to  the  researches  of  Luschka  and  Veit,  the  formation  of  new  muscu- 
lar fibres  is  limited  to  the  first  three  or  four  months  of  pregnancy. 

With  the  increase  in  the  number  and  size  of  the  muscle  fiores  is  asso- 

14.5 


Fig.  156. — Muscle  Fibres  from  Non-pregnant  and  Pregnant 
Uterus  (Sappey). 


146 


OBSTETRICS 


r*58S«K 


ciated  a  marked  development  affecting  the  blood-vessels,  especially  the 
veins,  which,  in  the  neighbourhood  of  the  placental  site,  become  converted 
into  large  spaces,  the  so-called  placental  sinuses-  Marked  hypertrophy  of 
the  lymphatic  andneiwous  supp_ly  of  the  uterus  also  takes  place,  of  the 
extent^bf  which  "some  idea"  may  be  gained  from  the  statement  of  Franken- 
hauser  that  the  cervical  ganglion  increases  in  size  from  2  X  2.5  to  6  X  4.5 
centimetres. 

During  the  first  few  months,  the  hypertrophy  of  the  uterus  results  from 
general  systematic  changes  induced  by  the  pregnancy  itself.  That  it  is 
not  directly  due  to  the  presence  of  the  ovum  in  the  cavity  itself  is  shown  by 
the  occurrence  of  precisely  similar  changes  in  cases  of  extra-uterine  preg- 
nancy, when  the  ovum  is  implanted  in  the  tube  or  ovary.    After  the  third 

month,  however,  the  increase  in 
size  is  mechanical  to  some  ex- 
tent, and  is  due  directly  to  the 
pressure  exerted  by  the  -grow- 
ing ovum. 

During  the  first  few  months 
of  pregnancy  the  uterine  walls 
are  considerably  thicker  than  in 
the  non-pregnant  condition,  but 
as  gestation  advances  they  grad- 
ually become  thinner,  so  that  at 
the  end  of  the  fifth  month  they 
are  from  3  to  5  millimetres  in 
thickness.  This  measurement  is 
retained  throughout  the  suc- 
ceeding months,  so  that  at  term 
the  uterus  is  represented  by  a 
muscular  sac  whose  walls  are 
rarely  above  5,  and  never  more 
than  10  millimetres  thick.  Oc- 
casionally they  are  found  to 
measure  considerably  under  5 
millimetres.  The  enlargement  of  the  uterus  is  not  symmetrical,  but  is 
most  marked  in  the  f undal  region.  This  can  readily  be  appreciated  by 
observing  the  relative  positions  of  the  insertions  of  the  tubes  and  ovarian 
ligaments,  which  in  the  early  months  of  pregnancy  are  almost  on  a  level 
with  the  fundus;  whereas  in  the  later  months  their  attachments  are  found 
at  points  slightly  above  the  middle  of  the  organ. 

The  position  of  the  placenta  also  exerts  a  determining  influence  upon 
the  extent  of  the  hypertrophy,  the  portion  of  the  uterus  to  which  it  is 
attached  enlarging  more  rapidly  than"* trip  others,  as~isTrkaiiv  shown  by 
the  position  of  the  uterrfte-cm^ls  of  the  rouncPligaments,  which  are  close 
together  when  the  placenta  is  inserted  upon  the  posterior,  and  far  apart 
when  it  is  upon  the  anterior  wall. 

Arrangement  of  the  Muscle  Fibres. — Ever  since  the  time  of  Vesalius, 
considerable  attention  has  been  devoted  to  the  arrangement  of  the  muscle 


Fig.  157. — External  Muscular  Later  of 
Pregnant  Uterus  (Helie). 


CHANGES    IX    TI1K    MATKRXAL   olKiAXIS.M 


117 


fibres  in  the  pregnanl  uterus.  Among  the  numerous  investigators  whose 
careful  studies  on  ihis  subjecl  deserve  special  mention  are  William  Hunter 
in  England;  .Madame  lioivin,  Se- 
ville, and  Helie  in  France;  Roederer, 
Luschka,  Henle,  Hoffmann,  Bayer, 
Hofmeier,  and  others  in  Germany. 
l/n  fortunately  thei  r  invest  igal  ions 
have  not    led  to   uniform    results. 

According  to  Luschka  and  Henle, 
the  musculature  of  the  pregnant  ute- 
rus is  arranged  in  three  strata:  an 
external  hood-like  layer,  which  arches 
over  the  fundus  and  extends  into  the 
various  ligaments;  an  internal  layer. 
consisting  of  sphincter-like  fibres 
around  the  orifices  of  the  tubes  and 
the  internal  os;  while  lying  between 
the  two  is  a  dense  network  of  muscle 
fibres  perforated  in  all  directions  by 
blood-vessels. 

The  most  important  contributions, 
however,  we  owe  to  Helie,  Bayer,  and 
Buge.  In  the  preface  to  his  mono- 
graph, Helie  tells  us  that  he  had  de- 
voted twelve  years  to  his  investiga- 
tions, and  Bayer  has  been  an  indefatigable  worker  upon  the  subject 
since  1886. 

According  to  Helie,  the  uterine  musculature  consists  of  3  main  layers, 
each  of  which  is  made  up  of  several  subsidiary  divisions.  The  external 
laveris  composed  of  2  longitudinal  or  ansiform  portions,  between  which  lie's 
a  transverse  layer.  The  internaHayer  is  composed  of  2  triangular  portions 
running  along  the  inner  surface  of  "the  anterior  and,  posterior  wails  of 

the  litems  respectively,  ancl 
connected  by  an  archiform 
layer  at  the  fundus,  an 
obicular  portion  around 
each  tubal  opening,  and 
an  annular  layer  around 
the  internal  os.  The  main 
portion  of  the  uterine  wall 
is  formed  by  the  middle 
layer,  which  consists  of  an 

Fig.  159.— Median  Muscular  Layer  of  Pregnant  interlacing  network^of  111US- 

Uteeus  (Helie).  cle    fibres,    between    which 

extend  the  blood-vessels. 
Each  fibre  comprising  this  layer  has  a  double  curve,  so  that  the  interlace- 
ment of  any  two  gives  approximately  the  form  of  the  figure  "Ji£,  As  a  result 
of  such  an  arrangement  it  happens  that  when  the  fibres  contract  they  con- 


Fig.  158. — Internal  Muscular  Layer  of 
Pregnant  Uterus  (Helie). 


148  OBSTETRICS 

strict  the  vessels  and  thus  act  as  living  ligatures.  Bayer's  work  is  extremely 
complicated,  and  those  who  desire  particulars  concerning  it  are  referred 
to  his  monographs,  upon  the  subject. 

Euge  pointed  out  that  many  of  the  layers  which  had  been  described 
by  previous  observers  do  not  exist  as  such  in  the  pregnant  uterus,  the 
appearances  having  resulted  from  the  manner  in  which  the  dissections  had 
been  made.  He  showed  that  the  muscle  fibres  composing  the  uterine  wall, 
specially  in  its  lower  portion,  overlap  one  another  and  are  arranged  more  or 
less  like  shingles  on  a  roof,  oneend  01  each  ft  ore  arising  beneath  the  peri- 
toneal covering  of  the  uterus,  and  extending  obliquely  downward  and 
inward,  to  be  inserted  into  the  decidua,  thus  giving  rise  to  a  large  number 
of  muscular  lamella3.  The  various  lamella?  are  connected  with  one  another 
by  short  muscular  processes,  so  that  when  the  tissue  is  slightly  spread  apart 
it  presents  a  sieve-like  appearance,  which  on  closer  examination  is  seen  to 
be  due  to  the  presence  of  innumerable  rhomboidal  spaces.  Euge  attaches 
great  importance  to  this  arrangement  of  the  muscle  fibres,  and  believes 
that  it  explains  very  satisfactorily  the  mechanism  of  the  uterine  contrac- 
tions and  the  manner  in  which  the  felt-like  structure  of  the  puerperal 
uterus  is  brought  about. 

Changes  in  Size  and  Shape  of  the  Uterus. — As  the  uterus  increases  in 
size,  it  also  undergoes  important  modifications  in  shape.  For  the  first  few 
weeks  its  oj:jgiiial  pyriform  outlines  are  retained,  but  the  body  and  fundus 
soon  assume  a  more  globularform,  which  at  the  third  or  fourth  month 
becomes  almost  spherical.  After  this  period,  however,  the  organ  increases 
more  rapidly  m  length  "than  in  width,  and  assumes  an  oval  form,  which 
persists  until  the  end  of  pregnancy. 

The  increase  in  the  size  of  the  uterus  is  limited  almost  entirely  to 
its  body,  the  cervix  remaining  practically  unchanged  until  the  onset  of 
labour,  so  that  throughout  the  course  of  pregnancy  it  appears  as  a  mere 
appendage  to  the  enlarged  body.  tits  most  characteristic  change  consists 
in  a  marked  softening,  which  is  readily  appreciated  by  the  examining 
finger,  and  constitutes  one  of  the  physical  signs  of  pregnancy.  The 
slight  increase  in  size  which  can  be  noted  is  due  in  great  part  to  in- 
creased vascularity,  and  depends  only  to  a  small  extent  upon  hyper- 
trophy of  its  muscle  fibres.  As  a  result,  the  secretion  of  the  cervical 
glands  becomes  more  copious  and  the  cervical  canal  becomes  filled  with 
a  plug  of  mucus.  The  changes  occurring  in  it  in  the  latter  part  of 
pregnancy  willbe  considered  in  detail  when  we  take  up  the  physiology 
of  labour. 

As  the  body  of  the  uterus  becomes  larger,  the  angle  which  it  forms  with 
the  cervix  becomes  smaller — in  other  words,  its  physiological  anteflexion 
is  increased.  As  pregnancy  advances  the  organ  soon  becomes  too  large 
to  be  contained  in  the  pelvic  cavity,  and  by  the  fourth  month  forms  a 
tumour,  the  upper  border  of  which  reaches  to  a  point  midway  between  the 
symphysis  pubis  and  the  umbilicus.  As  it  becomes  still  larger,  it  comes 
in  contact  with  the  anterior  abdominal  wall,  displacing  the  intestines  to 
the  sides  of  the  abdomen,  and  gradually  rises  up  until  it  almost  impinges 
upon  the  diaphragm.     As  the  uterus  leaves  the  pelvis  for  the  abdominal 


CHANGES    IX   THE   MATERNAL  ORGANISM 


140 


cavity,  considerable  tension  is  exerted  upon  the  broad  ligaments,  which 
then  become  more  or  less  unfolded  at  their  uterine  ends. 

The  pregnanl  uterus  possesses  a  considerable  degree  of  mobility.  Since 
iis  upper  portion  projects  into  and  lies  free  in  the  abdominal  cavity  and 
its  lower  portion  is  held  somewhal  in  check  by  the  lax  broad  ligaments  ii 
readily  changes  its  position.  With  the  woman  in  a  standing  posture 'its 
longitudinal  axis  corresponds  closely  will,  thai  of  the  superior  strait,  the 
organ  resting  in  greal  part  upon  the  anterior  abdominal,  wall.     In  this  posi- 


r 


L 

r 


F'g-  160.  Tig.  161. 

Iigs.  160,  161. — Same  Fill-term  I-paea  in  Vertical  axd  Horizontal  Position. 


tion  the  portion  projecting  above  the  symphysis  has  somewhat  more 
breadth  than  height.  With  the  woman  lying  on  her  back,  however,  the 
uterus  falls  backward  and  rests  upon  the  vertebral  column,  its  length 
being  now  greater  than  its  breadth.  Figs.  160  and  161  represent  the  same 
woman  in  the  upright  and  horizontal  positions  respectively,  and  give  a 
good  idea  of  the  changes  in  contour  of  the  uterus  and  abdomen. 

As  the  uterus  grows  out  of  the  pelvic  cavity,  it  usually  becomes  slightly 
twisted  to  jhe  right,  so  that  its  left"  margin  is  clirecteXlnore^nLe^KorTy"' 


Occasionally  the  torsion  may  be  in  the  opposite  direction. 


150  OBSTETRICS 

statistics  showing  that  it  occurs  to  the  right  in  80  per  cent  and  to  the  left 
in  20  per  cent  of  the  cases.  The  torsion  is  due  in  great  part  to  the  pres- 
ence of  the  rectum,  which  usually  occupies  the  left  side,  and  only  occa- 
sionally the  right  side,  of  the  pelvis;  though  possibly,  in  a  certain  number 
of  instances,  the  condition  represents  merely  an  exaggeration  of  the  orig- 
inal position  of  the  non-pregnant  uterus,  which,  as  is  well  known,  is  not 
always  perfectly  symmetrical.  From  my  own  observations,  I  am  inclined 
to  agree  with  "Webster,  that  the  frequency  with  which  torsion  of  the  uterus 
occurs  has  been  somewhat  exaggerated. 

With  the  advance  of  pregnancy  the  uterus  loses  the  firm,  almost  car- 
tilaginous consistence  which  is  characteristic  of  the  non-pregnant  condi- 
tion, and  becomes  converted  into  a  sac  having  very  thin,  soft  walls,  which 
are  readily  compressible.  This  is  well  demonstrated  by  the  ease  with  which 
the  foetus  can  be  palpated  in  some  cases,  and  by  the  fact  that  not  infre- 
quently it  is  possible  at  operation  to  observe  shallow  depressions  upon  the 
surface  of  the  uterus,  which  have  resulted  from  the  pressure  of  the  intes- 
tines upon  it.  Again,  it  is  noteworthy  with  what  readiness  the  uterine 
walls  yield  to  the  movements  of  the  foetal  extremities. 

Tubes  and  Ovaries. — As  has  already  been  mentioned,  the  tubes  and 
ovaries  undergo  marked  changes  in  position  with  the  advance  of  preg- 
nancy, so  that  instead  of  extending  outward  almost  at  right  angles  with 
the  cornua,  their  long  axes  become  nearly  parallel  tojthe  margins  of  the 
uterus.  Of  special  importance,  moreover,  is  their  increase  in  vascularity, 
to  which  the  large  size  of  the  corpus  luteum  of  pregnancy  is  in  great  part 
due.  Except  in  rare  instances,  ovulationceases  during  prponanr-yT  so  that 
new  follicles  do  not  ripen,  and,  accordingly,  only  the  single  large  corpus 
luteum  of  pregnancy  can  be  found  upon  the  surface  of  one  of  the  ovaries. 

Most  authors  believe  that  the  muscular  fibres  of  the  tubes  undergo  con- 
siderable hypertrophy  under  the  influence  of  pregnancy,  but  this  has  re- 
cently been  denied  by  Mandl,  and  it  must  be  admitted  that,  if  it  occurs  at 
all,  it  is  very  slight  in  extent.  It  is  possible  for  a  deeidua  to  develop  in 
the  tubes  while  the  pregnancy  is  situated  in  the  uterus]  Such  observations 
have  been  made  by  Webster,  Mandl,  and  Veit,  but  are  of  extreme  rarity. 
In  the  microscopic  study  of  the  tubes  from  10  or  12  cases  of  uterine  preg- 
nancy I  have  not  met  with  such  an  occurrence. 

Vagina. — Increased  vascularity  is  the  most  marked  change  in  the  va- 
gina, and  to  it  is  due  the  more  copious  secretion  and  the  characteristic 
violet  coloration  of  pregnancy.  At  the  same  time  there  is  considerable 
hypertrophy  of  the  elements  composing  the  vaginal  walls,  the  latter  not 
infrequently  increasing  in  length  to  such  an  extent  that  the  lo^-er  portion 
of  the  anterior  wall  prolapses  slightly  through  the  vulval  opening. 

The  papillae  of  the  vaginal  mucosa  also  undergo  considerable  hyper- 
trophy, whence  results  an  increased  roughness  of  the  membrane,  which 
in  occasional  instances  feels  almost  like  a  calf's  tongue.  Owing  to  the 
increased  vascularity,  the  vaginal  secretion  is  considerably  augmented, 
and  in  the  majority  of  cases  is  represented  by  a  thick,  white,  crumbly  sub- 
stance, somewhat  like  cottage  cheese.  Doderlein,  who  was  the  first  to 
direct  attention  to  its  characteristic  appearance,  showed  that  the  material 


CHANGES  IN  THE  MATERNAL  ORGANISM 


L51 


consisted  of  epithelial  cells  and  a  large  number  of  Long,  tolerably  thin 
bacilli.  The  same  authority  states  that  under  normal  conditions  ii  does 
n.ii  contain  leucocytes  or  pathogenic  micro-organisms. 

The  increased  vascularity  attending  pregnancy  is  not  confined  to  the 
genitalia,  but  extends  to  the  various  organs  in  their  vicinity,  and  as  a 
consequence  there  is  a  slight  relaxation  of  the  various  pelvic  joints,  which 
is  accompanied  by  an  increase  in  their  motility,  as  was  conclusively  shown 
by  Budin. 

Abdominal  Walls. — With  the  enlargement  of  the  uterus  the  skin  cover- 
in--  the  anterior  abdominal  walls  and  the  adjoining  portions  of  the  thighs 
is  subjected  to  considerable  tension,  which,  according  to  Marie  Schlee. 


Fig.  162. — Abdomen  of  Primipaea  at  Term,  showing  Stride. 


results  in  the  stretching  and  distortion  of  the  connective-tissue  spaces  of 
the  cutis,  and  the  formation  of  depressed  areas  which  are  known  as  the 
stria  of  pregnancy.  In  primiparae  these  present  a  pinkish  or  slightly  bluish 
appearance,  as  is  well  illustrated  in  Fig.  162,  whereas  in  multipara?  two 
varieties  are  observed,  some  resembling  those  of  primiparous  women,  while 
others  present  a  glistening  silvery  appearance,  the  former  resulting  from 
the  present  condition,  and  the  latter  representing  cicatrices  from  previous 
pregnancies. 

The  formation  of  stria?  is  not  characteristic  of  pregnancy,  as  it  is  lack- 


152  OBSTETRICS 

ing,  according  to  Crede,  in  about  10  per  cent  of  the  cases  and  is  not  infre- 
quently observed  in  non-pregnant  women  and  occasionally  in  men,  in 
whom  there  has  been  a  rapid  increase  in  the  size  of  the  abdomen, 
either  from  the  presence  of  a  tumour  or  ascites,  or  the  rapid  develop- 
ment of  fat. 

Not  infrequently  the  abdominal  walls  are  unable  to  withstand  the  ten- 
sion to  which  they  are  subjected,  and  the  recti  muscles  become  separated 
in  the  middle  line,  giving  rise  to  ^diastasis  of  greater  or  less  extent. 
Where  the  process  is  exaggerated,  a  considerable  portion  of  the  anterior 
wall  of  the  uterus  is  covered  by  nothing  beyond  a  thin  layer  of  tissue  con- 
sisting only  of  skin,  fascia,  and  peritonaeum.  In  rare  instances  the  sepa- 
ration is  sufficiently  extensive  to  admit  of  a  hernial  protrusion  of  the 
gravid  uterus. 

The  enlarged  pregnant  uterus  occasionally  presses  upon  the  venous 
trunks,  which  return  the  blood  from  the  lower  extremities,  the  obstruction 
being  sometimes  sufficient  to  cause  varicoseyeins  or  oedema.  The  -latter  is 
most  commonly  observed  about  the  ankteTahd  feel,  but  occasionally  occurs 
to  a  marked  degree  in  the  neighbourhood  of  the  vulva,  when  the  labia  ma- 
jora  may  become  immensely  distended.  Budin  some  years  ago  made  an  ex- 
haustive study  as  to  the  frequency  and  mode  of  production  of  varicose 
veins  in  pregnancy,  and  to  his  monograph  the  reader  is  referred  for  fur- 
ther information. 

Breasts. — Under  the  influence  of  pregnancy  marked  changes  occur  in 
the  breasts,  and  in  the  early  weeks  the  woman  not  infrequently  complains 
of  a  sense  of  tenseness  and  pricking  in  these  regions.  After  the  second 
month  the  breasts  begin  to  increase  in  size  and  offer  a  somewhat  nodular 
sensation  on  palpation,  which  is  due  to  the  hypertrophy  of  the  mammary 
alveoli,  and  as  they  become  still  larger  a  delicate  tracery  of  bluish  veins 
appears  just  beneath  the  skin.  The  most  characteristic  changes,  however, 
are  afforded  by  the  nipples  and  the  tissue  in  their  vicinity.  The  nipples 
themselves  soon  become  considerably  larger,  more  deeply  pigmented,  and 
more  erectile,  and  after  the  first  few  months  a  thin,  yellowish  fluid — 
colostrum — may  be  exj)ressed  from  them  by  gentle  massage.  At  the  same 
time  the  areola  surrounding  the  nipple  becomes  considerably  broader  and 
much  more  deeply  pigmented,  the  degree  of  pigmentation  varying  accord- 
ing to  the  complexion  of  the  individual.  In  blondes  the  areolae  and  nip- 
ples assume  a  pinkish  appearance,  while  in  brunettes  they  become  dark 
brown  and  occasionally  almost  black.  Scattered  through  the  areola  are 
a  number  of  small  roundish  elevations,  the  so-called  glands  of  Montr/ornery, 
which  result  from  the  hypertrophy  of  the  sebaceous  glands.  In  a  small 
number  of  cases  similar  structures  make  their  appearance  around  the 
periphery  of  the  areola,  and  are  then  designated  as  the  secondary  areola. 
If  the  increase  in  the  size  of  the  breasts  be  very  marked,  the  skin  not  in- 
frequently presents  striations  similar  to  those  observed  on  the  abdomen. 

Changes  in  the  Rest  of  the  Body. — The  changes  resulting  from  preg- 
nancy are  not  limited  to  the  generative  tract,  but  extend  to  other  portions 
of  the  body  as  well,  and  in  many  cases  the  general  condition  of  the  patient 
differs  markedly  from  what  it  was  before  conception.    Many  women  suffer 


CHANGES   IX   THE   MATERNAL   ORGANISM  153 

numerous  inconveniences  during  this  period,  while  others  enjoy  better 
health  than  at  any  other  time. 

Heart. — Owing  to  the  upward  pressure  upon  the  diaphragm,  the  heart 
becomes  displaced  in  such  a  way  that  its  area  of  dulness  undergoes  a 
considerable  increase  in  size.  Basing  bis  opinion  upon  this  fact,  Larcher 
in  182*!  promulgated  the  doctrine  that  considerable  cardiac  hypertrophy 
was  a  constant  concomitant  of  pregnancy.  His  views  obtained  rapid  ac- 
ceptance in  France,  but  were  received  with  scepticism  in  Germany.  Ger- 
hardt,  Lohlein,  Fellner,  and  others  stated  that  actual  weighing  of  the  preg- 
nant heart  showed  that  hypertrophy  did  not  occur. 

It  is  apparent  that  the  heart  must  perform  a  greater  amount  of  work 
during  this  period  than  at  other  times,  so  that  a  priori  the  occurrence  of 
hypertrophy  would  not  be  surprising.  Moreover,  the  recent  researches  of 
Dreysel  would  appear  to  indicate  that  it  does  take  place,  as  he  found  that 
the  hearts  of  TG  pregnant  and  puerperal  women  weighed  8.8  per  cent 
more  than  those  of  non-pregnant  individuals.  The  question,  however,  can- 
not be  regarded  as  definitely  settled,  and  offers  an  attractive  field  for  future 
work. 

Blood. — In  former  times  it  was  generally  believed  that  the  changes 
incident  to  the  placental  circulation  demanded  an  increase  in  the  amount 
of  maternal  blood,  and  all  the  earlier  writers  and  most  of  the  text-books 
stated  that  under  the  influence  of  pregnancy  an  increased  hydremia  and 
a  diminution  in  haemoglobin  and  red  corpuscles  took  place,  while  at  the 
same  time  an  abnormal  amount  of  fibrin  could  be  noted.  These  observa- 
tions were  based  upon  antiquated  methods  of  research,  and  it  was  not  until 
1886  that  Fehling,  by  the  aid  of  modem  appliances  for  examining  the 
blood,  came  to  the  conclusion  that  it  underwent  little  if  any  change. 

Since  then  a  number  of  articles  have  appeared  upon  the  subject,  the 
most  important  being  those  of  Eichard  Schroeder  in  1891,  and  Wild  in 
1897.  Both  of  these  writers  proved  that  in  the  later  months  of  pregnancy 
there  was  a  slight  increase  in  the  amount  of  haemoglobin  and  red  corpuscles, 
instead  of  a  decrease,  as  was  formerly  believed.  The  latter  investigator 
also  showed  that  there  was  a  slight  increase  in  the  number  of  white  cor- 
puscles, which  became  markedly  accentuated  during  the  first  few  days  of 
the  puerperium.  This  leucocytosis  he  attributed  to  the  changes  associated 
with  the  healing  of  the  wound  at  the  placental  site. 

Blumreich.  in  1899,  apparently  demonstrated  a  considerable  increase 
in  the  alkalinity  of  the  blood  in  pregnancy,  both  for  human  beings  and 
also  for  rabbits,  but  advanced  no  theory  as  to  its  significance. 

Kidneys.— During  pregnancy  the  urine  is  considerably  increased  in 
quantity,  though  otherwise  it  should  be  perfectly  normal  and  contain  the 
usual  amounts  of  urea  and  other  excrementitious  substances.  From  state- 
ments which  have  appeared  at  various  times  it  would  seem  that  consider- 
able misapprehension  exists  concerning  the  daily  amount  of  urea  excreted 
by  pregnant  women.  The  examination  of  the  urine  passed  in  twenty-four 
hours  bv  a  considerable  number  of  patients  at  the  Johns  Hopkins  Hos- 
pital has  led  us  to  believe  that  from  20  to  21  grammes  a  day  is  the  average 
quantity,  instead  of  the  larger  amount  generally  given. 


154:  OBSTETRICS 

Albumin  is  not  infrequently  observed  in  the  urine,  and  is  often  due 
to  its  admixture  with  vaginal  secretion.  Its  occurrence  in  catheterized 
specimens,  however,  should  always  be  regarded  as  pathological.  The 
significance  of  albuminuria  is  of  extreme  importance,  and  will  be  con- 
sidered in  the  chapter  dealing  with  the  diseases  incident  to  the  pregnant 
state. 

Throughout  pregnancy  there  is  a  marked  tendency  to  disturbances  in 
the  renal  function,  and  slight  degrees  of  nephritis  are  so  common  that  they 
are  assigned  by  the  Germans  to  "  the  kidney  of  pregnancy  "  (Sehwanger- 
schaftsniere).  The  condition  is  not  normal,  and  is  nearly  always  connected 
with  disturbances  of  metabolism,  which  give  rise  to  various  forms  of  auto- 
intoxication. 

Bladder. — As  the  uterus  rises  up  into  the  abdominal  cavity  it  carries 
with  it  the  bladder,  which  in  the  later  months  of  pregnancy  becomes  an 
abdominal  instead  of  a  pelvic  organ,  and  when  distended  can  be  felt  as 
a  fluctuant  tumour  just  above  the  symphysis  pubis. 

Lungs. — Owing  to  the  upward  displacement  of  the  diaphragm  in  the 
last  few  months  of  pregnancy,  it  would  seem  as  though  the  capacity  of 
the  lungs  would  be  decreased.  Nevertheless,  the  researches  of  Dohrn 
have  shown  that  such  is  not  the  case,  since  the  diminished  height  of  the 
pleural  cavities  is  compensated  for  by  an  increase  in  width,  except 
in  elderly  primiparaa  in  whom  the  costal  articulations  have  become 
ossified. 

Normally,  the  patient  gains  in  weight  during  the  last  three  months  of 
gestation.  This  is  not  entirely  due  to  the  increased  size  of  the  uterus  and 
its  contents,  but  to  a  considerable  extent  results  from  an  additional  de- 
posit of  fat  in  the  other  portions  of  the  body.  According  to  G-assner,  the 
normal  increase  for  the  last  three  months  is  from  1,600  to  2,500  grammes 
a  month  (3  to  5  pounds). 

Under  the  influence  of  pregnancy  abnormalities  of  pigmentation  are 
not  infrequently  noted.  One  of  the  most  common,  after  those  which  ap- 
pear in  the  breasts,  is  increased  pigmentation  along  the  linea  alba.  Again, 
in  pregnant  women  irregularly  shaped  yellowish  patches  of  varying  size 
occasionally  appear  on  the  face  and  neck,  the  condition  being  known  as 
cloasma. 

In  a  small  number  of  cases  the  thyroid  increases  markedly  in  size, 
though  we  are  ignorant  as  to  its  significance. 

We  have  already  referred  to  the  occurrence  of  oedema  and  varicose 
veins  as  a  result  of  pressure  exerted  by  the  pregnant  uterus  upon  the  veins 
passing  through  the  pelvis.  Xot  infrequently  disturbances  of  urination 
and  defecation  are  due  to  the  same  factor,  although,  as  a  ride,  the  constipa- 
tion is  caused  by  the  pregnant  uterus  interfering  with  the  contraction  of 
the  muscles  of  the  abdominal  wall. 

Functional  disturbances  of  the  nervous  system  are  not  infrequently  ob- 
served during  the  course  of  pregnancy,  the  most  frequent  being  the  nausea 
and  vomiting,  to  which  we  shall  refer  later.  In  a  small  number  of  cases 
varying  degrees  of  salivation  may  also  be  observed,  and  some  patients  dis- 
play a  longing  for  abnormal  articles  of  diet.     Again,  in  women  of  neuro- 


CHANGES   IX   THE   MATERNAL  ORGANISM  156 

pathic  tendencies,  the  mental  equilibrium  may  be  overthrown  to  a  greater 
or  less  degree,  the  patieni  becoming  excitable  or  morbid  and  morose,  and 
in  rare  instances  developing  a  true  psychosis. 

LITERATURE 

Bayer.    Zurphysiol.  u.  path.  Morphologie  der  Gebfirmutter.     Freund's  Gynakologische 

Klimk.  i.  369-662,  L885. 
Weitere  Beitrage  zur  Lclire  vom  unteren  Uterinsegment.    Hegar's  Beitrage  zur  Geb.  u. 

Gyn.,  i,  167,  1898. 
Blumreich.     Der  Einfluss  der  Graviditat  auf  die  Blutalkalescenz.     Archiv  f.  Gyn.,  lix, 

699,  1899. 
Boivin  ct  Dicks.     Traite  pratique  ties  maladies  de  1' uterus,  etc.,  2rae  ed.,  Bruxelles,  1834. 
Budin.     Des  varices  chez  la  femme  enceinte.     Paris,  1880. 
Crede.     Ueber  die   narbenahnlichen    Streifen   in   der  Haut,  etc.,  bei   Schwangeren  u. 

Entbundenen.     Monatsschr.  f.  Geburtskunde,  xiv,  321-333,  1859. 
Deville.     Bull,  de  la  Soe.  anatomique,  1844,  quoted  in  extenso  by  Cazeaux,  Traite  de 

l'art  des  accoucheraents,  3me  ed.,  107-111,  1850. 
Doderleix.     Das  Scheidensekret,  etc.     Leipzig,  1892. 
Dohrx.     Zur  Kenntniss  des  Einflusses  von  Schwangerschaft  etc.  auf  die  vitale  Capaeitat 

der  Lungen.     Monatsschr.  f.  Geburtskunde,  xxviii,  457,  1866. 
Dreysel.     Ueber  Herzhypertrophie  bei  Schwangeren  und  Wochnerinnen.    D.  I.,  Miinchen, 

1891. 
Fehlixg.      Ueber  Blutbeschaffenheit   und    Fruchtwassermenge   bei   Schwangeren,   etc. 

Archiv  f.  Gyn.,  xxviii,  453,  1886. 
Fellxer.     Herz  und  Schwangerschaft.     Monatsschr.  f.  Geb.  u.  Gyn..  xiv,  370-417,  1901. 
Fraxkexhauser.     Die  Nerven  der  Gebarmutter.     Jena,  1867. 
Gassxer.     Ueber  die  Veranderungen  des  Korpergewichtes  bei  Schwangeren.    Monatsschr. 

f.  Geburtskunde,  xix,  1,  1862. 
Gerhardt.     De  situ  et  magnitudine  cordis  gravidarum.     Jena,  1862. 
Helie.     Recherches  sur  la  disposition  des  fibres  musculaires  de  l'uterus  developpes  par  la 

grossesse.     Paris,  1864. 
Hexle.     Eingeweidelehre,  II.  Aufl.,  476,  1873. 
Hoffjiaxx.     Morphologische    Utersuchungen    iiber   die   Muskulatur    des   Gebarmutter- 

korpers.     Zeitschr.  f.  Geb.  u.  Frauenkraukheiten,  1876,  i,  448-473. 
Hofmeier.     Das  untere  Uterinsegment  in  anat.  u.  physiol.  Beziehung.     Der  schwangere 

und  kreissende  Uterus,  Bonn,  1886,  21-74. 
Huxter.     The  Anatomy  of  the  Gravid  Uterus,  1774. 
Joessel  und  Waldeyer.     Das  Becken,  781.     Bonn,  1899. 
Krause.     Quoted   by  Spiegelberg-Wiener,  Lehrbuch   der   Geburtshiilfe,  III.   Aufl.,  53, 

1891. 
Larcher.    Quoted  from  Ribemont-Dessaignes  and  Lepage,  Precis  d'obstetrique.     Paris, 

1894. 
Lohleix.     Ueber  das  Verhalten  des  Herzens  bei  Schwangeren,  etc.     Zeitschr.  f.  Geb.  u. 

Frauenkraukheiten.  1876,  i,  482-516. 
Luschka.     Die  Anatomie  des  menschlichen  Beckens,  365.  Tubingen,  1864. 
Maxul.      Ueber  den   feineren  Bau  der   Eileiter,  etc.      Monatsschr.   f.  Geb.  u.  Gyn.,   v 

(Erganzungsheft,  130-140),  1897. 
Roederer.     Icones  uteri  humani.  7.     Gottingen,  1759. 
Ruge.     Ueber  die  Contraction  des  Uterus  in  anat.  u.  klin.  Beziehung.     Zeitschr.  f.  Geb, 

u.  Gyn..  v,  149-157.  1880. 
Schi.ee.     Ueber  die  Dehnung  der  Bauchwand  wahrend  der  Schwangerschaft.     Zeitschr. 

f.  Geb.  u.  Gvn.,  xiii,  1-14,  1886. 


156  OBSTETRICS 

Scheoeder,  R.     Untei'suchungen  iiber  die  Beschaffenheit  des  Blutes  von  Schwangeren 

und  Wochnerinnen.     Archiv  f.  Gyn.,  xxxix,  306-352,  1891. 
Veit.     Anatomie  des  schwangeren  Uterus.     Muller's  Handbuch  der  Geburtshiilfe,  i,  193, 


Decidual  Formation  in  Tube  in  a  Case  of  Uterine  Pregnancy.     Schroeder's  Lehrbuch 
der  Geburtshulfe,  XIII.  Aufl.,  101,  1899. 
Webster.    Ectopic  Pregnancy.     Edinburgh,  1895. 
A  Criticism  of  Recent  Views  regarding  the  Lateral  Deviation  and  Rotation  of  the 
Uterus.     Edinburgh  Med.  Jour.,  September,  1897,  254-261. 
Wild.     Untersuchungen  iiber  den  Hamoglobingehalt  und  die  Anzahl  der  rothen  und 
weissen  Blutkorperchen  bei  Schwangeren  und  Wochnerinnen.     Archiv  f.  Gyn.,  liii, 
363-381,  1897. 


CHAPTER   VII 

DIAGNOSIS  OF  PREGNANCY— DURATION  OF  PREGNANCY— 
ESTIMATION  OF  DATE  OF  CONFINEMENT 

Ordinarily,  the  diagnosis  of  pregnancy  offers  little  or  no  difficulty, 
and  the  patient  is  usually  aware  of  the  true  condition  before  she  consults 
a  physician.  In  a  small  minority  of  cases,  however,  the  task  is  by  no 
means  easy,  and  despite  every  known  method  at  our  command  we  are  occa- 
sionally unable  to  decide  with  absolute  certainty. 

Mistakes  in  diagnosis  are  most  frequently  made  in  the  first  few  months, 
while  the  uterus  is  still  a  pelvic  organ;  although  it  is  by  no  means  impos- 
sible to  confound  a  pregnane)*,  even  at  full  term,  with  a  tumour  of  some 
other  nature.  Such  errors  are  usually  the  result  of  hasty  or  imperfect 
examination,  but  a  false  conclusion  may  sometimes  be  arrived  at.  even  after 
the  most  conscientious  exploration  of  the  patient.  Some  idea  of  the  fre- 
quency of  such  mistakes  may  be  realized  when  it  is  stated  that  there  is 
hardly  a  gynecologist  of  experience  who  has  not  opened  the  abdomen  on 
one  or  more  occasions,  with  the  expectation  of  removing  a  tumour  of  the 
uterus  or  its  appendages,  and  been  surprised  to  find  himself  in  the  presence 
of  a  normal  pregnancy. 

It  is  often  a  matter  of  considerable  importance  that  a  diagnosis  be 
made  in  the  early  months  of  pregnancy;  but,  unfortunately,  it  is  just  at 
this  period  that  our  diagnostic  ability  is  most  restricted,  as  the  absolutely 
positive  signs  do  not  as  a  rule  become  available  until  the  fifth  month. 
Hence  it  follows  that  in  cases  in  which  the  existence  of  such  a  condition 
might  affect  the  reputation  or  interests  of  the  patient,  an  expression  of 
opinion  should  be  deferred  until  the  diagnosis  is  beyond  all  doubt. 

Signs  and  Symptoms  of  Pregnancy. — The  diagnosis  is  based  upon  the 
presence  of  certain  symptoms  and  signs.  The  former  are  chiefly  subjec- 
tive and  are  appreciated  by  the  patient;  while  the  latter  are  made  out  by 
the  physician  after  a  careful  physical  examination,  in  which  the  senses  of 
sight,  hearing,  and  touch  are  employed. 

The  signs  and  symptoms  are  usually  classified  into  three  groups:  posi- 
tive, probable,  and  presumptive.  The  positive  sir/ns  cannot  usually  be 
detected  until  after  the  fourth  month,  and  are  three  in  number:  (1)  hear- 
ing  and  r-nnntrng  The  foetal  hpart-'rje*at:  (2)  perception  of  the  active  and 
passive  movementa^f  the  foetus:  and  (3)  the  ability  to  map  out  its  out- 
lines. The  probable  sir/ns  can  be  appreciated  at  a  much  earlier  period,  and 
are:  (1)  changes  in  the  shape  and  consistency  of  the  body  of  the  uterus; 
11  157 


158  OBSTETRICS 

(2)  changes  in  the  cervix;  (3)  the  detection  of  intermittent  uterine  con- 
tractions; and  (4)  increase  in  the  size  of  the  abdomen  and  uterus.  The 
presumptive  evidences,  with  a  few  exceptions,  are  subjective,  and  may  be 
experienced  at  varying  periods.  They  are:  (1)  cessation  of  the  menses;  (2) 
changes  in  the  breasts;  (3)  morning  sickness;  (4)  quickening;  (5)  Chad- 
wick's  sign;  (6)  disturbances  in  urination;  (7)  abnormalities  in  pigmenta- 
tion; (8)  abnormal  cravings;  and  (9)  mental  disturbances. 

Positive  Signs  of  Pregnancy. — The  Foetal  Heart. — Whenever  we  can  hear 
and  count  the  pulsations  of  the  foetal  heart,  we  know  that  we  have  a 
characteristic  and  absolute  sign  of  pregnancy;  unfortunately,  it  is  one 
that  cannot  usually  be  appreciated  until  the  eighteenth  or  twentieth  week, 
though  occasionally  the  sounds  can  be  heard  at  an  earlier  period,  and  on 
one  occasion  I  was  able  to  detect  them  as  early  as  the  fourteenth  week. 

The  foetal  heart  was  first  heard  by  Mayor,  of  Geneva,  in  1818,  in  a 
few  cases.  The  sign  was  also  discovered  independently  by  Lejumeau  de 
Kegaradec  in  1821,  to  whom  we  are  indebted  for  most  of  our  information 
upon  the  subject;  indeed,  so  complete  is  his  monograph  that  subsequent 
investigations  have  revealed  but  little  with  which  he  was  not  familiar. 
He  made  his  discovery  quite  accidentally,  while  attempting  to  hear  the 
sounds  which  the  foetus  made  by  splashing  in  the  liquor  amnii.  On  aus- 
cultating the  abdomen  of  a  pregnant  woman  through  her  clothing,  includ- 
ing the  corset,  he  heard  a  double  sound,  which  varied  in  frequency  from  -143 
to  148  beats  to  the  minute,  and  closely  resembled  the  ticking  of  a  watch 
under  a  pillow.  He  concluded  that  it  could  be  produced  only  by  the 
foetal  heart,  as  the  pulse  of  the  mother  did  not  exceed  70.  For  further 
details  concerning  the  history  and  earlier  work  upon  the  subject,  the 
reader  is  referred  to  the  works  of  Kegaradec,  Kennedy,  Depaul,  and  Mont- 
gomery. 

As  has  already  been  said,  the  foetal  heart-beat  cannot  usually  be  heard 
until  the  eighteenth  or  twentieth  week  of  pregnancy,  but  from  then  on 
it  should  be  detected  without  Hiffieulty.  Ordinarily  it  varies  in  frequency 
from  120  to  140  beats  to  the  minute,  and  is  a  double  sound,  closely  resem- 
bling the  tick  of  a  watch  under  a  pillow.  In  order  to  hear  it  the  abdomen 
should  be  bared,  or  at  most  covered  by  a  thin  cloth.  In  the  earlier  months 
it  is  best  detected  by  means  of  a  stethoscope,  but  at  a  later  period  the 
direct  application  of  the  ear  gives  satisfactory  results.  It  is  advisable  for 
the  student  to  perfect  himself  in  the  latter  method  of  auscultation,  as  he 
always  has  his  ears  with  him,  but  occasionally  may  be  without  his  stetho- 
scope. One  should  not  be  content  with  merely  hearing  the  foetal  heart, 
but  should  always  attempt  to  count  its  rate  and  compare  it  with  that  of 
the  maternal  pulse. 

In  the  earh*  months  of  pregnancy  the  heart  should  be  sought  just  over 
the  symphysis  pubis;  but.  in  the  later  months  the  situation  at  which  it  is 
best  heard  varies  according  to  the  position  and  presentation  of  the  foetus, 
details  concerning  which  will  be  given  when  we  consider  the  methods  of 
obstetrical  examination. 

The  rate  of  the  foetal  heart  is  subject  to  considerable  variations,  which 
afford  us  a  fairly  reliable  means  of  judging  as  to  the  well-being  of  the 


POSITIVE  skins  OF   PREGNANCY  L59 

child.    As  a  general  rule,  its  life  should  be  considered  in  danger  when  the 
heart-beats  fall  below  LOO  or  exceed  L60. 

In  women  possessing  very  thin  abdominal  and  uterine  walls,  the  Im- 
pulse of  the  foetal  heart  may  occasionally  be  appreciated  by  direct  palpa- 
tion, especially  when  the  child  is  lying  in  the  right  mento-iliac  position. 
Such  observations  have  been  reported  by  Fischel,  Duval,  and  other.. 

Frankenhauser  stated  that  there  was  a  marked  difference  in  the  rapidity 
of  the  heart-beal  in  the  two  sexes,  and  believed  that  a  rate  of  124  or  less 
indicated  a  boy,  and  144  or  more  a  girl.  Further  investigation,  however, 
has  tailed  to  confirm  his  conclusions,  as  the  diagnosis  of  sex  can  be  made 
by  this  means  in  only  about  50  per  cent  of  the  cases.  Indeed,  there  is  no 
method  by  which  the  sex  can  be  definitely  determined  before  birth,  except 
in  a  few  cases  of  breech  presentation,  in  which  the  genitalia  can  be  differ- 
entiated by  the  examining  finger. 

Other  Sounds  which  may  be  Heard  on  Auscultation. — In  addition  to 
hearing  and  counting  the  fcetal  heart,  auscultation  of  the  abdomen  of  the 
woman  in  the  later  months  of  pregnancy  often  reveals  other  sounds,  the 
most  important  of  which  are  the  funic  souffle,  the  uterine  or  placental 
souffle,  those  due  to  movements  of  the  foetus,  foetal  heart  murmurs,  the  ma- 
ternal pulse,  and  the  gurgling  of  gas  in  the  intestines  of  the  mother. 

The  funic  souffle  is  a  sharp,  whistling  sound,  synchronous  with  the  foetal 
pulse,  which  can  be  heard  in  about  15  per  cent  of  all  cases.  It  is  very 
inconstant  in  its  appearance,  as  it  may  be  recognised  distinctly  at  one  exam- 
ination and  be  absent  on  succeeding  occasions.  It  was  first  described  by 
Evory  Kennedy,  who  supposed  that  it  was  due  to  some  interference  with 
the  circulation  of  the  blood  through  the  umbilical  arteries,  and  subsequent 
investigations  have  served  to  confirm  his  conclusions.  Occasionally,  in 
very  thin  women,  the  umbilical  cord  can  be  palpated  between  the  body  of 
the  child  and  the  uterine  wall,  and  on  making  pressure  upon  it  with  the 
stethoscope  a  distant  souffle  can  occasionally  be  elicited.  This  is  not, 
however,  a  sign  of  very  great  importance,  although,  when  heard,  it  is  dis- 
tinctly characteristic  of  pregnancy. 

In  rare  instances,  abnormalities  of  the  foetal  heart  have  been  diagnosed 
by  auscultation  during  pregnancy.  Such  cases  have  been  reported  by 
Fochier,  Cordell,  and  others,  and  have  been  confirmed  at  autopsy  after 
birth. 

The  uterine  souffle  is  a  soft,  blowing  sound,  synchronous  with  the  ma- 
ternal pulse,  and  is  usually  most  distinctly  heard  upon  auscultating  the 
lower  portion  of  the  uterus.  It  is  due  to  the  passage  of  blood  through  the 
dilated  uterine  vessels.  This  sound  was  first  described  by  Kegaradec,  who 
considered  that  it  was  produced  by  the  circulation  of  the  blood  through 
fhe  placenta,  and  he  therefore  designated  it  as  the  placental  souffle,  and 
believed  that  it  was  of  value  in  determining  the  situation  of  that  organ. 
Subsequent  investigations,  however,  have  shown  that  such  is  not  the  case, 
and  that  the  sound  originates  as  I  have  indicated,  and  should  therefore  be 
designated  as  the  uterine  souffle.  As  stated  by  Eotter  and  others,  it  may 
occasionally  be  appreciated  by  the  palpating  finger.  This  sign  is  not  char- 
acteristic of  pregnancy,  as  it  may  be  present  in  any  condition  in  which  the 


160  OBSTETRICS 

blood  supply  to  the  genitalia  becomes  markedly  increased,  and  accordingly 
is  not  infrequently  heard  in  non-pregnant  women  presenting  tumours  of 
the  uterus  or  ovaries. 

Certain  movements  of  the  foetus  may  likewise  be  recognised  on  ausculta- 
tion. According  to  Ahlf  eld,  it  is  impossible  to  hear  the  movements  of  the 
extremities,  and  he  considers  that  the  sounds  which  are  usually  so  inter- 
preted are  produced  by  spasmodic  contractions  of  the  diaphragm,  and  are 
analogous  to  singultus. 

Not  infrequently  the  maternal  pulse  can  be  distinctly  heard  on  auscul- 
tating the  abdomen,  and  in  some  instances  the  pulsation  of  the  aorta  is 
so  violent  as  to  communicate  a  distinct  throb  to  the  ear. 

In  addition  to  the  sounds  just  mentioned,  it  is  not  unusual  to  hear 
certain  others  produced  by  the  passage  of  gases  or  fluids  through  the  intes- 
tines of  the  mother. 

Mapping  out  the  Outlines  of  the  Foetus. — In  the  latter  half  of  preg- 
nancy it  is  possible  to  distinguish  the  outlines  of  the  foetus  by  palpation 
through  the  abdominal  walls,  and  this  becomes  easier  the  nearer  term  is 
approached.  When  we  desire  to  map  out  the  foetus  we  should  go  about 
the  examination  in  a  methodical  manner,  and  follow  the  rules  for  palpation 
which  will  be  given  later. 

A  diagnosis  of  pregnancy  should  not  be  made  from  this  sign  alone, 
unless  one  is  able  to  feel  distinctly  the  various  portions  of  the  foetus  and 
distinguish  its  head,  breech,  back,  and  extremities.  Subserous  myomata 
occasionally  simulate  the  head  or  small  parts,  or  both,  and  their  presence 
has  occasionally  given  rise  to  serious  diagnostic  errors. 

Movements  of  the  Foetus. — The  third  positive  sign  of  pregnancy  is 
present  whenever  the  physician  is  able  to  feel  the  movements  of  the  foetus. 
These  are  active  or  passive,  according  as  they  are  made  spontaneously  by  the 
foetus,  or  are  imparted  to  it  by  the  examining  hand. 

After  the  fifth  month,  active  movements  may  be  felt  on  placing  the 
hand  over  the  abdomen.  These  vary  from  a  faint  nutter  in  the  early 
months  to  quite  violent  motions  at  a  later  period,  which  not  infrequently 
are  visible  as  well.  Occasionally,  somewhat  similar  sensations  may  be 
produced  by  contractions  of  the  intestines  or  the  muscles  of  the  abdominal 
wall,  though  these  should  not  deceive  an  experienced  observer. 

The  passive  movements,  obtained  by  ballottement,  consist  in  the  rebound 
of  a  foetal  extremity  when  displaced  from  its  position  by  the  examining 
finger,  whereby  a  sensation  is  afforded  similar  to  that  produced  when  a 
sudden  motion  is  given  to  a  piece  of  ice  in  a  glass  of  water,  so  that  at  first 
it  sinks  and  then  slowly  comes  back  to  the  finger.  This  sign  is  available 
from  the  early  part  of  the  fourth  month,  and  may  be  obtained  through 
either  the  vagina  or  the  abdominal  walls.  To  obtain  vaginal  ballottement 
the  patient  should  be  on  her  back;  the  physician  then  introduces  two  fin- 
gers into  the  vagina  and  carries  them  up  to  the  anterior  fornix,  to  which 
he  imparts  a  sudden  motion  with"  his  finger-tips,  afterward  retaining  them 
in  the  same  position.  After  a  moment  the  extremity  of  the  child  which 
occupies  the  lower  segment  of  the  uterus,  usually  the  head,  drops  down 
upon  them  again. 


I'liol'.ABLK   SKINS   OF    L'REGNANCY 


101 


External  ballottenjejii  can  be  obtained  by  imparting  a  sudden  motion 
to  the  portion  ofihv; abdominal  wall  covering  the  uterus;  in  a  few  seconds 
Hi,,  rebound  of  one  of  the  extremities  of  the  foetus  can  be  felt.  This  sign 
is  of  very  considerable  value,  and  can  only  be  simulated  by  a  pedunculated 
tumour  swimming  in  ascitic  fluid.  When  any  one  of  the  three  positive 
signs  is  obtained,  the  diagnosis  of  pregnancy  is  established  beyond  doubt. 

Probable  Signs  of  Pregnancy. —  Enlargement  of  Ilie  A'bilonien. —  From  the 
third  month  onward  the  uterus  can  be  felt  through  the  abdominal  walls  as 


/ 


% 


} 


-   . 


t-'KS^ 


Fig.  163.  Fig.  164.  Fig.  165.  Fig.  166. 

Figs.  163-166. — Showing  Kelative  Abdominal   Enlargement  at  Third,   Sixth,  Ninth,  and 

Tenth  Month  of  Pregnancy. 


a  tumour,  which  gradually  increases  in  size  up  to  the  end  of  pregnancy. 
Generally  speaking,  any  enlargement  of  the  abdomen  during  the  childbear- 
ing  period  should  be  regarded  as  prima  facie  evidence  of  the  existence  of 
pregnancy.  Figs.  163,  164,  165,  and  166  give  a  good  idea  of  the  changes 
in  the  shape  of  the  abdomen  at  the  various  months. 

The  abdominal  enlargement  is  far  less  pronounced  in  primiparae  than 
in  multipara?,  for  the  reason  that  in  the  latter  the  abdominal  walls  have 
lost  a  great  part  of  their  tonicity  and  are  sometimes  so  flaccid  that  they 
afford  little  or  no  support  to  the  uterus,  which  then  becomes  markedly 


162 


OBSTETRICS 


anteflexed  and  sags  forward  and  downward,  giving  rise  to  a  pendulous 
abdomen.  It  should  also  be  borne  in  mind  that  the  abdomen  changes  its 
shape  materially  according  as  the  woman  is  in  the  upright  or  horizontal 
position,  being  much  less  prominent  when  she  is  lying  down.  (See  Figs. 
160  and  161.) 

Changes  in  Size,  Shape,  and  Consistency  of  Uterus. — In  the  first  three 
months  these  are  the  only  physical  signs  available,  and  the  existence  of  an 
enlarged  uterus  at  any  time  during  the  childbearing  period  should  be  regarded 
as  presumptive  evidence  of  pregnancy,  until  such  a  possibility  has  been  con- 
clusively eliminated. 

During  the  first  few  weeks  the  increase  in  size  is  limited  almost  entirely 
to  the  antero-posterior  diameter;  but  at  a  little  later  period  the  body  of 

the  uterus  becomes  almost 
globular  in  shape,  and  at 
the  third  month  attains 
the  size  of  an  orange. 
During  the  first  two 
months  the  pregnant  ute- 
rus still  continues  to  be 
entirely  a  pelvic  organ, 
whereas  during  the  third 
month  it  begins  to  rise 
above  the  symphysis.  At 
the  same  time  the  angle 
between  the  body  and 
cervix  becomes  markedly 
accentuated — in  other 
words,  the  physiological 
anteflexion  is  increased. 

More  characteristic 
than  the  changes  in  shape 
are  those  affecting  its  con- 
sistency. On  bimanual  ex- 
amination the  uterine 
body  offers  a  dougbjt.  or 
elastic  sensation,  and  in 
many  instances  becomes  so  soft  as  to  be  hardly  distinguishable.  Dickinson 
has  pointed  out  that  these  changes  can  be  noted  at  a  very  early  period,  and 
states  that  he  was  able  to  differentiate  a  symmetrical  elastic  area  in  the  body 
of  the  uterus  in  the  latter  part  of  the  first  week  of  pregnancy,  which  he  con- 
sidered almost  pathognomonic. 

According  to  E.  von  Braun,  it  would  appear  that  the  earliest  evidence 
of  pregnancy  is  afforded  by  the  appearance  of  a  more  or  less  longitudinal 
furrow  upon  either  the  anterior  or  posterior  surface  of  the  uterus.  Its  pres- 
enceNhe  attributes  to  changes  in  consistence  and  the  alteration  between 
contraction  and  relaxation  of  the  portion  of  the  organ  in  which  the  ovum 
is  situated.  Von  Braun  claims  that  this  sign  enables  him  to  diagnose  the 
existence  of  pregnancy  as  early  as  the  first  week. 


Fig.  167. — Pendulous  Abdomen  of  a  Multipaeous  Woman 
with  Normal  Pelvis. 


l'i;n|;.\I'.I.i:   SHINS   OF    PREGNANCY 


L63 


At  about  the  sixth  week  another  sign  of  considerable  value — the  so- 
called  Hegar's  sign — becomes  available.  <  >n  careful  bimanual  examination 
with  one  hand  upon  the  abdomen  and  two  fingers  of  the  other  hand  in  the 
vagina,  or  with  a  finger  in  the  rectum  and  the  thumb  in  the  vagina,  the 


Fig.  168. — Method  of  detecting  Hegak's  Sign. 


firm,  hard  cervix  is  felt,  while  above  it  is  the  elastic  body  of  the  uterus, 
and  between  the  two  quite  a  soft  compressible  area.  Occasionally  the 
change  in  consistence  of  the  lower  segment  of  the  uterus  is  so  marked  that 
no  connection  between  the  cervix  and  body  appears  to  exist,  and  in  not  a 
few  instances  inexperienced  observers  have  mistaken  the  cervix  for  the 
uterus,  and  the  softened  body  for  a  tumour  of  the  uterine  appendages. 

This  sign,  first  described  by  Eeinl  in  1884,  was  verified  later  by  Sonn- 
tag  and  others,  and  its  value  is  now  universally  admitted.  Its  production 
probably  depends  upon  the  forcing  of  the  part  of  the  ovum  occupying  the 
lower  uterine  segment  into  the  upper  part  of  the  body  of  the  uterus,  so 
that  the  empty  and  softened  lower  uterine  segment  can  then  be  readily 
compressed  between  the  fingers.  Fig.  168  gives  a  good  idea  of  the  sensation 
to  be  obtained  on  bimanual  examination;  and  Figs.  169  and  1T0  show  the 
condition  of  the  uterus  which  makes  it  possible.  This  sign  is  of  very 
considerable  value,  and  its  presence  leaves  but  little  doubt  as  to  the 
diagnosis. 


164 


OBSTETRICS 


Cervix. — Beginning  with  the  second  month  of  pregnancy  the  cervix 
becomes  considerably  softened,  and  in  primrpSrous  women  the  os  externum 
offers  to  the  finger  a  sensation  similar  to  that  obtained  by  pressing  upon 
the  more  yielding  lips  instead  of  the  harder  cartilage  of  the  nose,  as  at 
other  times.  In  some  cases,  however,  this  sign  does  not  become  available, 
as  in  certain  inflammatory  conditions  of  the  uterus,  as  well  as  in  carci- 
noma, the  cervix  may  remain  firm  and  hard  throughout  the  entire  duration 
of  pregnancy. 

Intermittent  Contractions  of  the  Uterus. — From  the  third  month  on, 
at  intervals  of  fromfive  to  ten  minutes,  the  pregnant  uterus  undergoes 
painless  contractions,  which  in  the  early  months  can  be  appreciated  by 
bimanual  examination,  and  later  by  the  hand  upon  the  abdomen,  when 


Fig.  169. — Ten-weeks'  Pregnant  Uteeus 
(Piuard).     XX. 


Fig.  170.- 


-Showing  Mode  oe  Peoduction 
of  Hegae's  Sign. 


the  previously  relaxed  organ  is  felt  to  become  firm  and  hard,  remaining  so 
for  a  few  moments,  and  then  returning  to  its  original  condition.  Attention 
was  first  called  to  this  phenomenon  by  Braxton  Hicks,  and  the  sign  has 
since  been  known  by  his  name.  It  is  not,  however,  infallible,  as  similar 
contractions  are  sometimes  observed  in  hgematometra,  and  occasionally  in 
cases  of  submucous_nryomata. 

Whenever  one  or  several  of  these  probable  signs  of  pregnancy  are  de- 
tected the  evidence  becomes  very  strong.  Nevertheless,  if  there  is  any  pos- 
sibility of  wronging  our  patient  we  are  not  justified  in  making  a  positive 
assertion,  even  though  we  may  feel  morally  sure  of  our  diagnosis. . 

Presumptive  Signs  of  Pregnancy. — The  presumptive  evidences  of  preg- 
nancy are  afforded  in  great  part  by  subjective  symptoms,  which  are  appre- 
ciated by  the  patient  herself. 

Cessation  of  the  Menses. — Most  important  is  the  cessationof  the  men- 
strual  flow.  In  women  exposed  to  the  possibility  of  pregnancy,  and  whose 
meTTsee-have  previously  been  regular,  a  sudden  cessation  is  a  most  char- 
acteristic sign;  and  from  it  alone  the  majority  of  married  women  do  not 
hesitate  to  diagnose  their  condition.  But  in  patients  presenting  an  irregu- 
lar menstrual  history  this  symptom  does  not  possess  the  same  diagnostic 


PRESUMPTIVE  SIGNS  OP  PREGNANCY  L65 

value,  and  we  also  know  that  certain  diseases  may  give  rise  to  amenorrhoea 
of  many  months'  duration,  in  the  course  of  which  conception  occasion- 
ally occurs. 

Not  infrequently  a  single  menstrual  period  may  be  missed  by  women 
who  fear  the  possibility  of  pregnancy;  ami  false  statements  are  often  made 
in  the  hope  of  misleading  the  physician  ami  inducing  him  to  introduce  a 
sound  or  Mime  other  instrument  into  the  uterus,  ami  thereby  provoke  an 
abortion. 

In  not  a  few  instances  menstruation  may  appear  once  after  the  com- 
mencement of  pregnancy,  though  the  How  is  usually  less  profuse  than  at 
other  times.  In  many  of  these  cases  it  is  probable  that  conception  has 
occurred  shortly  before  the  period,  although  this  rule  by  no  means  univer- 
sally holds  good.  Only  very  rarely,  however,  does  the  menstrual  flow 
appear  more  than  once,  and  its  regular  recurrence  should  always  arouse 
suspicion  as  to  the  existence  of  disease  of  the  endometrium,  carcinoma  of 
the  cervix,  or  some  other  pathological  condition. 

One  occasionally  hears  of  women  who  menstruate  regularly  throughout 
pregnancy,  but  the  majority  of  these  accounts  are  apocryphal,  or  else  the 
condition  is  associated  with  uterine  disease.  At  the  same  time  it  must  he 
admitted  that  very  exceptionally  authentic  cases  are  observed,  and  in  a 
patient  recently  under  my  charge,  the  most  careful  examination  revealed 
no  other  source  for  the  haemorrhage.  Such  an  occurrence,  however,  should 
never  be  taken  for  granted,  and  all  other  possibilities  must  be  carefully 
excluded. 

Changes  in  the  Breasts. — In  the  chapter  upon  the  Physiology  of  Preg- 
nancy reference  has  'already  been  made  to  the  changes  which  occur  in  the 
breasts.  Generally  speaking,  in  primfparae  these  are  quite  characteristic, 
but  are  of  less  value  in  multipara?,  since  the  breasts  of  the  latter  not  infre- 
quently contain  a  small  amount  of  milk  or  colostrum  for  months,  and  even 
for  years,  following  the  last  labour.  Occasionally,  changes  in  the  breasts 
similar  to  those  produced  by  pregnancy  may  be  observed  in  women  suf- 
fering with  ovarian  or  uterine  tumours.  Xor  is  the  possibility  of  their 
occurrence  excluded  in  instances  of  spurious  or  imaginary  pregnancy. 

Xausea  and  Vomiting. — The  establishment  of  pregnancy  is  not  infre- 
quently marked  by  disturbances  of  the  digestive  system,  more  particularly 
manifested  by  nausea  and  vomiting.  This  "morning  sickness"  as  the 
name  implies,  usually  comes  on  in  the  earlier  part  of  the  day,  and  passes  off 
in  a  few  hours,  although  it  occasionally  persists  longer  or  ma}'  occur  at 
other  times.  It  usually  appears  about  the  end  of  the  first  month,  and 
lasts  for  six  or  eight  weeks,  although  some  patfelfts  suffer  from  it  for  a 
much  longer  period. 

There  is  considerable  discrepancy  of  opinion  as  to  the  frequency  with 
which  these  symptoms  are  observed.  According  to  Gardner,  they  occur 
in  only  about  15  per  cent  of  the  cases,  but  my  experience  is  that  probably 
one  half  of  pregnant  women  suffer  from  them  to  a  greater  or  lesser  degree. 
In  many  it  amounts  to  nothing  more  than  an  occasional  sensation  of 
nausea;  others  have  considerable  vomiting,  while  in  rare  instances  the 
nausea  and  vomiting  may  be  so  persistent  and  constant  as  to  seriously  in- 


166  OBSTETRICS 

terfere  with  nutrition.  Occasionally,  similar  symptoms  result  from  nerv- 
ousness or  from  the  fear  of  an  illegitimate  pregnancy,  as  well  as  in  certain 
cases  of  pseudocyesis. 

Quickening. — About  the  eighteenth  or  twentieth  week,  the  woman  be- 
comes consensus  of  slight,  fluttering  movements  in  her  abdomen,  which 
gradually  increase  in  intensity.  These  are  usually  due  to  movements  of  the 
foetus,  and  their  first  appearance  is  designated  as  "  quickening  "  or  the 
perception  of  life.  Occasionally  foetal  movements  may  be  perceived  as 
early  as  the  tenth  week,  while,  on  the  other  hand,  in  rare  instances  they 
may  not  be  experienced  at  all. 

This  sign  offers  only  corroborative  evidence  of  pregnancy,  and  is  of 
no  value  unless  confirmed  by  the  hand  of  the  physician,  as  in  many 
nervous  women  similar  sensations  are  experienced  in  its  absence. 

Discoloration  of  the  Mucous  Membrane  of  Vagina  and  Vulva. — Under 
the  influence  of  pregnancy  the  margins  of  the  vaginal  opening  and  the 
lower  portion  of  the  anterior  vaginal  wall  frequently  take  on  a  somewhat 
dark  bluish  or  purplish,  congested  appearance.  Attention  was  first 
called  to  this  condition^By  Jaequemier  and  Kluge,  but  particular  stress 
was  laid  upon  its  significance  by  Dr.  James  E.  Chadwick,  of  Boston,. so  that 
in  this  country  it  is  known  as  ChadiricVs  sign.  Its  presence  supplies  valu- 
able presumptive  evidence,  but  is  not  conclusive,  as  it  may  likewise  be 
observed  in  any  condition  leading  to  intense  congestion  of  the  pelvic 
organs. 

Pigmentation  of  the  Shin  and  Abdominal  Strice. — These  manifestations, 
which  have  already~T5een  refeired  to  in  Lhe  chapter  upon  the  physiology 
of  pregnancy,  are  usually  observed  in  this  condition,  but  are  not  absolutely 
characteristic  of  it,  as  they  are  sometimes  associated  with  tumours  of  other 
origin. 

Urinary  D isturbances. — In  the  early  weeks  of  pregnancy  the  enlarging 
uterus,  byexertmg  pressure  on  the  bladder,  causes  a  desire  for  frequent^ 
micturition.     This  is  most  marked  in  the  first  few  months,  and  gradually 
passes  off  a'sMhe  uterus  rises  up  into  the  abdomen,  to  reappear  when  the 
head  descends  into  the  pelvis  a  few  weeks  before  term. 

Cravings — Mjnhd_jjjid^motional  Changes. — Occasionally  the  appetite 
of  the  pregnant  woman  becomes1  Tery  capricioTis,  and  she  may  evince  an 
almost  unconquerable  desire  for  peculiar  and  sometimes  revolting  articles 
of  food.  I  recall  one  patient  who  subsisted  almost  exclusively  upon 
devilled  crabs  throughout  the  entire  duration  of  pregnancy,  and  another 
who  could  retain  nothing  for  the  first  four  months  except  broiled  lobster 
and  Bass's  ale. 

We  have  already  referred  to  the  mental  and  emotional  changes  which 
sometimes  characterize  pregnancy,  and  occasionally  we  meet  with  women 
who  diagnose  their  condition  mainly  from  the  occurrence  of  changes  in 
their  own  temperament  with  which  they  have  become  familiar  in  previous 
pregnancies. 

Synopsis  of  Signs  and  Symptoms  of  Pregnancy. — For  convenience  of 
reference,  we  give  a  synopsis  of  the  signs  and  symptoms  of  pregnancy,  di- 
viding them  into  three  groups  corresponding  to  three  different  periods. 


DIFFERENTIAL    DIAGNOSIS   OF    PREGNANCY  1*'»7 

The  first  belongs  to  the  Bret  three  months,  the  second/to  the  fourth  and 

fifth  months,  and  thenhird  to  the  last  five  i iths  of  pregnancy. 

In  the  first  period  tin.'  symptoms  are:  (")  cessation  <>[  the  menses;  (h) 
changes  in  the  breasts;  (c)  morning  sickness;  (d)   urinary  disturbances. 

The  signs  are:  (1)  enlargement  of  the  body  <>!'  the  uterus  and  increased 
anteflexion;  (2)  changes  in  the  consistency  of  the  body  of  the  uterus;  (3) 
Hegar's  sign;  ( 1)  changes  in  the  cervix;  (5)  Chadwick's  sign;  (G)  the  abdo- 
men is  nut  prominent,  the  navel  is  depressed;  (7)  auscultation  is  negative. 

Second  period.  Symptoms:  (a)  menses  still  absent;  (&)  more  marked 
changes  in  the  breasts;  (c)  disappearance  or  subsidence  of  gastric  and  uri- 
nary disturbances;  (<l)  quickening.  Signs:  (1)  the  fundus  is  felt  several 
fingers  above  the  symphysis  at  the  fourth  month,  and  midway  between  the 
symphysis  and  umbilicus  at  the  fifth  month;  (2)  the  cervix  is  soft;  (3) 
ballottement  is  obtainable;  (-1)  intermittent  uterine  contractions  are  recog- 
nisable; (."))  at  the  very  end  of  the  period  the  foetal  heart  sounds  can  be 
distinguished. 

Third  period.  Symptoms:  (a)  menses  still  absent;  (b)  changes  in  the 
breasts  more  marked;  (c)  in  the  last  month  frequent  urination  reappears, 
often  with  neuralgic  pains  in  the  lower  extremities.  Signs:  (1)  progressive 
enlargement  of  the  abdomen;  (2)  umbilicus  smooth  and  later  protruding; 
(3)  the  foetal  heart  can  be  heard;  (4)  the  different  parts  of  the  child  can 
be  palpated;  (5)  foetal  movements  are  perceptible. 

In  the  first  period  the  diagnosis  is  usually  very  probable,  but  never  ab- 
solute; in  the  second,  very  rarely  doubtful,  and  in  the  third  absolute. 

Differential  Diagnosis  of  Pregnancy. — The  pregnant  uterus  is  often 
mistaken  for  other  tumours  occupying  the  pelvic  or  abdominal  cavities, 
and  vice  versa,  though,  as  a  rule,  the  former  mistake  is  more  frequently 
made.  The  early  periods  of  pregnancy  may  be  simulated  by  enlargement 
of  the  uterus  due  to  interstitial  or  submucous  myomata,  sarcomata,  hamia- 
tometra.  and  conditions  resulting  from  inflammatory  disturbances.  As  a 
rule,  the  uterus  under  these  circumstances  is  harder  and  firmer  than  in 
pregnancy,  and  does  not  present  its  characteristic  elastic  or  boggy  con- 
sistency. Moreover,  such  conditions  are  not,  as  a  rule,  attended  by  cessation 
of  the  menses,  except  in  hamiatometra.  If,  however,  there  is  any  possibility 
of  a  mistake,  a  delay  of  a  few  weeks  will  usually  clear  up  the  diagnosis. 

The  pregnant  uterus  is  occasionally  mistaken  for  small  ovarian  or 
tubal  cysts,  though  this  error  should  not  occur  if  the  patient  be  carefully 
examined  bimanually  and  the  pelvic  contents  isolated,  if  necessary  under  an 
anaesthetic.  As  the  tumour  becomes  larger  and  rises  up  into  the  abdomen, 
other  points  become  available  for  differential  diagnosis,  notably  the  inter- 
mittent contractions  of  Braxton  Hicks  and  the  positive  signs  of  preg- 
nancy. 

The  diagnosis  of  pregnancy  in  a  myomatous  uterus  often  presents  seri- 
ous difficulties,  and  for  a  time  may  be  impossible.  But  a  short  delay  will 
show  a  more  rapid  increase  in  the  size  of  the  tumour  than  is  consistent 
with  the  existence  of  an  uncomplicated  myoma,  and  variations  in  the  con- 
sistency of  different  parts  should  also  serve  to  direct  one's  attention  to  the 
pregnant  condition. 


168 


OBSTETRICS 


Occasionally,  an  ovarian  cystoma  may  be  complicated  by  pregnancy. 
In  the  early  stages  the  diagnosis,  as  a  rule,  can  be  easily  made,  as  careful 
bimanual  examination  should  enable  one  to  differentiate  between  the  two 
tumours;  but  in  the  later  months  it  may  become  extremely  difficult  and 
sometimes  impossible,  owing  to  the  increased  distention  of  the  abdomen. 
Furthermore,  if  the  positive  signs  of  pregnancy  cannot  be  elicited,  its  exist- 
ence is  usually  overlooked  and  a  simple  cystoma  diagnosed;  whereas,  if  the 
heart  sounds  are  heard,  the  cystoma  may  escape  recognition  and  the  exces- 
sive abdominal  enlargement 'be  attributed  to  a  hydramnios. 

In  rare  instances  hypertrophy  of  the  supravaginal  portion  of  the  cervix 
may  seriously  increase  the  difficulties  of  diagnosis,  as  the  enlarged  and 

hard  cervix  may  be  mistaken 
for  the  entire  uterus,  the  soft 
and  elastic  body  being  either 
overlooked  or  regarded  as  a  tu- 
mour of  the  uterine  appendages. 
Careful  bimanual  examination 
under  anaesthesia  should  do 
away  with  the  possibility  of 
this    error. 

Irregular  development  of 
the  pregnant  uterus,  associated 
with  a  sacculation  of  its  ante-] 
rior  or  p^gWior  wall^-may  seri-f 
ously  complicate  the  diagnosis, 
especially  if  the  foetus  be  dead; 
as  even  after  the  most  careful 
examination  the  existence  of 
pregnancy  may  remain  unrec- 
ognised and  the  sacculation  be 
mistaken  for  an  ovarian  cyst. 
This  is  especially  apt  to  occur 
when  the  pregnancy  develops 
in  the  posterior  wall,  as  the  an- 
terior wall  may  remain  practi- 
cally unchanged,  and  when,  under  anaesthesia,  one  can  feel  the  fundus  with 
both  tubes  extending  from  it,  it  is  almost  a  pardonable  error  to  conclude 
that  the  fluctuant  tumour  lying  posterior  to  it  is  an  ovarian  cvsl.  _ 

Spurious  Pregnancy. — Imaginary  pregnancy,  or  j^uflnrypM^  is  .a,  condi- 
tion with  which  almost  every  practitioner,  sooner  or  later,  will  meet.  It 
is  usually  observed  in  patients  nearing  the  menopause  or  in  young  women 
who  intensely  desire  offspring.  Such  patients  may  present  all  the  sub- 
jective symptoms  of  pregnancy,  associated  with  a  marked  increase  in  the 
size  of  the  abdomen,  which  is  due  either  to  an  abnormal  and  rapid  deposi- 
tion of  fat  or  to  the  existence  of  tympanites  and  occasionally  of  ascites. 
When  it  occurs  in  the  earlier  years  of  life  the  menses  do  not,  as  a  rule,  dis- 
appear, but  may  present  certain  abnormalities  which  the  patient  considers 
are  due  to  her  condition. 


Fig.  171. — Abdominal  Enlargement  due  to  Fat, 
the  Patient  imagining  herself  to  be  in  the 
Last  Month  of  Pregnancy. 


DIAGNOSIS  OF   DEATH   OF    FCETTTS  L69 

In  many  instances  the  woman  may  imagine  that  she  detects  foetal  mi 
ments,  which  are  sometimes  so  violent  as  to  make  her  fearful  that  they 
may  be  visible  to  onlookers.  1  recently  saw  a  patient  who  imagined  her- 
self in  the  last  month  of  pregnancy,  and  who,  while  talking  to  me, 
claimed  at  the  violence  <>i'  tin-  movements,  but  on  examination  I  found  that 
Ikt  uterus  was  normal  in  size,  and  that  her  enlarged  abdomen  was  due  to  a 
rapidly  increasing  deposit  of  fat. 

The  supposed  foetal  movements  usually  result  from  contractions  of  the 
intestines  or  the  muscles  of  the  abdominal  wall,  and  occasionally  are  bo 
marked  lis  to  deceive  even  physicians.  Careful  examination  of  the  patient 
usually  enables  one  to  arrive  at  a  correct  diagnosis  without  great  difficulty, 
as  the  small  uterus  can  be  demonstrated  on  bimanual  examination,  made, 
if  necessary,  under  anaesthesia.  The  greatest  difficulty  in  these  cases  is  to 
persuade  the  patient  as  to  the  correctness  of  the  diagnosis. 

Distinction  between  First  and  Subsequent  Pregnancies. — Occasionally 
it  is  a  matter  of  practical  importance  to  decide  whether  a  patient  is  preg- 
nant for  the  first  time  or  has  previously  borne  children.  Ordinarily  child- 
bearing  leaves  indelible  traces  behind  it,  which  are  readily  appreciated; 
but  very  exceptionally  such  signs  are  lacking,  as  in  a  case  reported  by 
Budin.  (See  Fig.  33.)  Again,  in  very  rare  instances,  all  the  signs  indicat- 
ing a  previous  labour  may  result  from  the  previous  existence  of  a  large 
tumour  which  has  been  removed  through  the  vagina. 

In  a  pregnant  woman  who  has  never  borne  children  the  abdomen  is 
usually  tense  and  firm,  and  the  uterus  is  felt  through  it  onlv  with  difficulty. 
The  characteristic  pinkish  bluish  stria;  and  the  distinctive  changes  in  the 
breasts  are  readily  observed.  The  labia  majora  are  usually  in  close  apposi- 
tion,  the  frermlmrj  is  intact,  and  the  hymen  torn  in  several  places.  The 
vagina  is  usually  narrow  and  marked  by  well-developed  rugae.  The  cervix 
is  softened,  but  does  not  usually  admit  the  tip  of  the  finger  until  the  very 
end  of  pregnancy;  and  during  the  last  four  to  six  weeks  of  pregnancy  the 
presenting  part  is  found  engaged  in  the  superior  strait,  unless  some  dis- 
proportion exists. 

In  multiparous  women,  on  the  other  hand,  the  abdominal  walls  are 
usually  lax,  flabby,  and  frequently  pendulous,  and  the  uterus  is  readily 
palpated  through  them.  In  addition  to  the  pinkish  striae  due  to  the  pres- 
ent condition,  the  silvery  cicatrices  of  past  pregnancies  may  also  be  noted. 
The  breasts  are  usually  not  as  firm  as  in  the  first  pregnancy,  and  frequently 
present  stria?  similar  to  those  observed  on  the  abdomen.  The  vulva  is 
usually  more  or  less  gaping,  the  frenulum  has  disappeared,  and  the  hymen 
is  replaced  By  the  rrrnrarulrp  riv/rtiformes._  The  external  os,  even  in  the 
early  months  of  pregnancy,  usually  shows  signs  of  laceration,  and  at  a 
little  later  period  readily  admits  the  tip  of  the  finger,  which  can  be  carried 
up  to  the  internal  os.  Furthermore,  in  the  majority  of  cases  the  present- 
ing part  does  not  engage  in  the  superior  strait  until  the  onset  of  labour. 

Diagnosis  of  the  Life  or  Death  of  the  Foetus. — Generally  speaking,  the 
foetus  should  be  considered  to  be  alive  unless  definite  evidence  to  the  con- 
trary can  be  adduced.  In  the  early  months  of  pregnancy  the  diagnosis  of 
its  death  offers  considerable  difficulty,  and  can  only  be  made  after  repeated 


170  OBSTETRICS 

examinations  have  demonstrated  that  the  uterus  has  remained  stationary 
in  size  for  a  number  of  weeks. 

In  the  later  months  of  pregnancy,  the  disappearance  of  fcetal  move- 
ments usually  directs  the  attention  of  the  patient  to  this  possibility,  after 
which  she  suffers  from  ill-defined  sensations,  such  as  chilliness,  languor,  a 
sensation  of  weight Jn  the  abdomen,  and  perHaps  a  foul  taste  in  the  mouth. 
Careful  investigation  shows  that  the  litems  does  not  correspond  in  size 
with  the  estimated  duration  of  pregnancy,  and  perhaps  has  become  smaTTeTr 
than  previously;  while  at  the  same  time  retrogressive  changes  have  oc- 
curred in  the  breasts,  which  have  become  soft  and  flabby.  The  diagnosis  of 
the  condition,  however,  can  be  considered  absolute  only  after  repeated  ex- 
aminations, when  in  addition  to  the  signs  just  mentioned  one  has  failed 
to  hear  the  fcetal  heart  or  perceive  the  movements  of  the  child. 

Positive  information  is  occasionally  afforded  when  it  is  possible  to  rec- 
ognise by  palpation  the  macerated  skull  through  the  partially  dilated 
cervix;  whenever  one  can  feel  that  the  bones  of  the  head  are- loose  and 
present  a  sensation  as  if  they  were  contained  in  a  flabby  bag,  the  diagnosis 
can  be  made  at  once  without  hesitation. 

Duration  of  Pregnancy. — As  we  have  no  means  of  ascertaining  the 
exact  date  at  which  fertilization  occurs,  it  is  apparent  that  absolutely 
accurate  statements  as  to  the  duration  of  pregnancy  cannot  be  made; 
although,  as  has  already  been  pointed  out,  conception  usually  occurs  either 
soon  after  the  last  appearance  of  JJie  jnenses^  or  shortly  before  the  first 
period  which  is  missed.  In  rare  instances  it  takes  place  in  the  middle  of 
theinter-nienstrual  period.  These  views  have  been  confirmed,  not  only 
from  the  study  of  the  condition  of  the  ovaries,  but  also  by  the  experience 
of  embryologists,  as  it  is  not  unusual  for  young  embryos,  which  should 
be  of  the  same  age  when  we  calculate  from  the  last  menstrual  period,  to 
present  marked  variations  in  development. 

Usually  labour  ensues  about  two  hundred  and  eighty  days  (ten  lunar 
months)  after  the  beginning  of  the  last"  nlehslrual  period,  so"  that  the 
approximate  duration  of  pregnancy  is  two  hundred  and  seventy  days,  sup- 
posing that  conception  has  occurred  within  the  few  days  immediately  fol- 
lowing the  menstrual  flow.  This  rule,  however,  is  subject  to  manv  excep- 
tions, as  apparently  well-developed  children  may  be  born  as  early  as  the 
two  hundred  and  fortieth,  and  as  late  as  the  three  hundred  and  twentieth 
day  after  the  last  menstrual  period,  and  there  is  no  doubt  that  in  excep- 
tional instances  the  actual  duration  of  pregnancy  may  equal,  if  not  exceed, 
three  hundred  days. 

Every  one  practising  obstetrics  occasionally  meets  with  cases  in  which 
the  patient  believes  that  she  has  passed  a  month  beyond  term;  or,  in  other 
words,  that  the  pregnancy  has  lasted  eleven  instead  of  ten  lunar  months. 
This  belief,  however,  is  usually  erroneous,  as  in  the  majority  of  such  cases 
conception  has  not  occurred  until  just  before  the  first  period  which  was 
missed.  Exceptionally,  however,  pregnancy  may  last  for  an  abnormally 
long  period,  and  I  recall  a  patient  who  on  two  occasions  did  not  fall  into 
labour  until  considerably  over  eleven  months  after  the  last  period.  In 
both  instances  she  had  typical  labour  pains  at  the  end  of  the  tenth  month, 


DURATION   OF   PREGNANCY  171 

which  after  lasting  a  shorl  time  subsided,  and  did  not  return  for  more. 
than  lour  weeks.  Both  children  weighed  over  L2  pounds,  and  were  55  to 
56  centimetres  in  Length,  besides  presenting  markedly  increased  thoracic 
measurements. 

Even  when  we  know  the  date  of  the  coitus  from  which  the  pregnancy 
has  resulted,  we  are  in  no  better  position  to  estimate  the  actual  length 
of  pregnancy,  inasmuch  as  Lowenhardt  has  pointed  out  that  two  women 
may  have  fruitful  coitus  on  the  same  day,  and  yet  the  date  of  their  de- 
liveries may  vary  markedly.  Ahlfeld  analyzed  425  cases  in  which  the 
dale  of  coitus  was  supposed  to  be  known,  and  found  the  average  duration 
of  pregnancy  to  be  2G9.91  days;  but  individual  cases  in  the  series  presented 
marked  differences,  varying  from  two  hundred  and  thirty-one  to  three 
hundred  and  twenty-nine  days. 

Similar  differences  are  reported  by  veterinarians,  who  usually  date  the 
beginning  of  pregnancy  from  a  single  coitus.  According  to  Franck-Al- 
brecht-Gdring,  the  average  duration  of  pregnancy  in  the  mare  is  three 
hundred  and  sixty-six  days,  but  in  a  large  series  of  cases  individual  varia- 
tions between  three  hundred  and  seven  and  four  hundred  and  twelve  days 
were  noted.  In  the  cow  the  normal  duration  is  placed  at  two  hundred  and 
eighty  days,  with  extremes  of  two  hundred  and  forty  and  three  hundred 
and  eleven  days. 

In  view  of  these  facts  we  must  conclude  that  the  duration  of  pregnancy 
varies  within  certain  limits,  which  probably  depend  upon  individual  pe- 
culiarities, just  as  happens  in  the  case  of  mares  and  cows  of  different  races. 
Again,  as  Mme.  Laurie  has  recently  shown,  it  also  depends  upon  the  extent 
to  which  the  patient  can  spare  herself  in  the  last  three  months  of  pregnancy. 
This  observer  found  that  it  was  twenty  days  longer  in  1,550  women  who 
lived  comfortably  in  a  hospital  for  several  months  prior  to  delivery,  as  com- 
pared with  the  same  number  of  women  who  entered  at  the  onset  of  labour. 
Her  figures,  then,  go  to  show  that  hard  work  in  poorly  nourished  women 
predisposes  somewhat  to  the  premature  ending  of  pregnancy. 

It  must  also  be  admitted  that  the  duration  of  pregnancy  not  infre- 
quently exceeds  two  hundred  and  eighty  days  from  the  last  menstrual 
period,  and  that  when  it  lasts  much  longer  large  children  are  developed, 
which  are  frequently  delivered  only  after  great  difficulty.  Thus,  whenever 
the  menstrual  history  of  the  patient  indicates  that  she  has  passed  much 
beyond  the  tenth  and  is  approaching  the  eleventh  lunar  month,  we  should 
consider  the  propriety  of  the  induction  of  labour,  provided  that  careful 
examination  shows  that  the  child  is  larger  than  usual. 

Estimation  of  the  Probable  Bate  of  Confinement. — Unfortunately  for 
the  comfort  of  the  physician,  as  well  as  of  the  patient,  we  possess  no  reliable 
means  of  estimating  the  exact  date,  but  are  obliged  to  content  ourselves 
with  the  method  proposed  by  Xaegele,  which  is  based  upon  the  belief  that 
labour  occurs  two  hundred  and  eighty  clays  from  the  beginning  of  the  last 
menstrual  period.  The  calculation  is  readily  made  by  adding  seven  clays  to 
the  date  at  which  the  last  menstrual  period  first  appeared,  and  then  count- 
ing back  three  months.  For  example,  if  the  last  period  began  on  January 
10,  1902,  we  add  seven  days,  making  January  17th,  and  count  back  three 


172 


OBSTETRICS 


months,  thus  fixing  upon  October  17,  1902,  as  the  probable  date  of  con- 
finement. 

In  a  small  number  of  cases  the  patient  will  be  confined  on  the  precise 
day  estimated,  and  in  the  great  majority  of  cases  within  a  few  days  of 
this  date;  but  occasionally  a  period  of  several  weeks  may  elapse  before 
labour  occurs.  This  marked  difference  is  probably  due  to  the  fact  that  in 
the  one  case  conception  had  occurred  soon  after  the  last  period,  and  in 
the  latter  just  before  the  first  period  which  was  missed.  Accordingly, 
the  physician  should  hesitate  to  predict  a  definite  day  for  the  confine- 
ment, and  should  always  allow  a  margin  of  two  to  three  weeks  in  his  cal- 
culations. 

Lowenhardt  believed  that  the  duration  of  pregnancy  was  not  ten  lunar 
months,  but  ten  menstrual  periods,  and  considered  the  labour  as  likely  to 
occur  when  the  tenth  menstrual  period  following  conception  fell  due.  Ac- 
cording to  this  calculation,  in  patients  menstruating  at  intervals  of  twenty- 
six  and  thirty  days,  for  example,  the  duration  of  pregnancy  would .  be 
two   hundred  and   sixty  and  three  hundred   days  respectively.      In   the 

long  run,  however,  this 
method  of  calculation 
does  not  give  more  ac- 
curate results  than  that 
of  Xaegele. 

Occasionally  the  pa- 
tient believes  that  she 
can  date  her  pregnancy 
from  a  single  coitus, 
and  prefers  to  estimate 
the  approaching  date  of 
confinement  from  that 
rather  than  from  the 
beginning  of  the  last 
period.  This  method 
is  also  subject  to  con- 
siderable error,  as  we 
have  no  means  of  ascer- 
taining how  long  the 
spermatozoa  may  re- 
main in  the  genital 
tract  before  concep- 
tion   occurs. 

In  not  a  few  in- 
stances, especially  in 
nursing  women,  con- 
ception may  take  place 
during  a  period  of  amenorrhcea,  and  the  patient  is  often  surprised  by  the 
enlargement  of  her  abdomen  or  by  the  perception  of  foetal  movements; 
while  occasionally  the  first  intimation  that  she  is  pregnant  is  given  by  the 
fact  that  her  milk,  which  has  previously  agreed  very  well  with  the  infant, 


Fig.  172. — Kelative  Height  of  the  Fundus  at  the  Various 
Weeks  of  Pregnancy. 


ESTIMATION   OF   THE    DATE   OP   CONFINEMENT  173 

suddenly  becomes  indigestible.  [Jnder  such  circumstances,  the  usual  meth- 
ods of  calculation  are  of  no  value,  and  we  have  to  depend  upon  other  mean-, 
which,  unfortunately,  arc  extremely  unsatisfactory. 

Frequent  attempts  have  been  made  to  estimate  the  date  of  confine- 
ment, by  adding  twenty  or  twenty-one  weeks  to  the  date  upon  which  the 
patient  first  perceived  foetal  movements.  This  method  is  founded  on  the 
belief  that  uuickeningis  first  experienced  at  the  eighteenth  or  twentieth 
week  of  pregnancy.  Unfortunately,  this  assumption  is  erroneous,  as  the 
symptom  not  infrequently  occurs  at  a  much  earlier  period,  and  sometimes 
not  until  considerably  later. 

In  other  cases,  our  calculations  are  based  upon  the  enlargement  of  the 
abdomen  and  the  height  to  which  the  fundus  of  the  uterus  has  risen. 
Generally  speaking,  we  find  that  the  fundus  at  the  fourth  month  is  several 
fingers'-breadths  above  the  symphysis  pubis;  at  the  fifth  month  midway  be- 
tween it  and  the  umbilicus;  at  the  sixth  month  at  the  level  of  the  umbili- 
cus; at  the  seventh  month  three  fingers'-breadths  above  the  umbilicus; 
at  the  eighth  month  an  equal  distance  above  its  position  at  the  seventh 
month;  at  the  ninth  month  just  below  the  xiphoid;  whereas  in  the  last 
month,  particularly  in  primiparous  women,  it  sinks  downward  and  assumes 
almost  the  position  it  occupied  at  the  eighth  month. 

This  method,  however,  gives  only  approximate  results,  as  the  position 
of  the  umbilicus  is  subject  to  marked  variations.  Thus,  according  to 
Spiegelberg,  its  situation  varies  from  13  to  28  centimetres  above  the 
symphysis,  so  that  if  this  author's  figures  are  correct,  there  may  be  a 
difference  of  6  inches  in  its  position.  On  this  account  it  has  been  thought 
preferable  by  some  authors  to  estimate  the  distance  of  the  fundus  from 
the  symphysis  pubis  with  a  tape  measure,  the  average  results  obtained  by 
Spiegelberg  being  as  follows: 

22d  to  28th  week 24  to  24.5  centimetres. 

28th  week 26.7  centimetres. 

30th     "     28.4 

32d      " 29 . 5  to  30  centimetres. 

34th     "     31  centimetres. 

36th     "     32 

38th     "     33 . 1  centimetres. 

40th     "     33.7 

These  measurements,  however,  are  subject  to  considerable  variations, 
as  they  are  dependent  not  only  upon  the  size  of  the  foetus  contained 
within  the  uterus,  but  also  upon  the  degree  of  distention  of  the  abdominal 
contents.  Nevertheless,  in  cases  in  which  we  possess  no  other  data,  they 
occasionally  afford  us  information  of  very  considerable  value. 

LITERATURE 

Ahlfeld.    Beobachtungen  uber  die  Dauer  der  Schwangersehaft.    Monatsschr.  f.  Geburtsk., 
1869,  xxxiv,  180-225. 
Die  wahrnehmbaren  kindlichen  Bewegungen.     Lehrbnch  der  Gebnrtshiilfe.  IT.  Aufl., 
1898,  56. 
vox  Braux.     Leber  Friihdiagnose  der  Graviditat.     Centralbl.  f.  Gyn.,  1899,  488,  489. 
12 


174  OBSTETRICS 

Budin.     Femmes  en  couches  et  nouveau-nes.     Paris,  1897,  1-4. 

Chadwick.     Value  of  the  Bluish  Coloration  of  the  Vaginal  Entrance  as  a  Sign  of  Preg- 
nancy.    Trans.  Amer.  Gyn.  Soc,  1886,  xi,  399. 
Cordell.    Congenital  Anomaly  of  the  Foetal  Heart,  etc.,  in  which  a  Systolic  Murmur  was 

heard  before  Birth.     Trans.  Med.  and  Chirurg.  Faculty  of  Maryland,  1884,  218-222. 
Depaul.     Traite  d'auscultation  obstetricale.     Paris,  1847. 
Dickinson.     The  Diagnosis  of  Pregnancy  between  the  Second  and  Seventh  Weeks  by 

Bimanual  Examination.     Amer.  Gyn.  and  Obst.  Journal,  1892,  ii,  544-555. 
Duval.     Palpation  of  the  Foetal  Heart  Impulse  in  Pregnancy.    Johns  Hopkins  Hospital 

Bulletin,  1897,  viii,  p.  207. 
Fischel.     Ueber  ein  bisher  nicht  beobachtetes  Phanomen  bei  Deflexionslagen.     Prager 

med.  Wochenschr.,  1881,  Nr.  12,  13;  1882,  Nr.  28. 
Zur  intrauterinen  Tastbarkeit  des  fotalen  Herzimpulses  bei  Deflexionslagen.   CentralbL 

f.  Gyn.,  1885,  769-771. 
Fochier.     Sur  le  bruit  de  souffle  d'origine  foetale.     L'Obstetrique,  1896,  i,  279. 
Franck-Albrecht-Goring.      Die  Trachtigkeitsdauer,  Thierarztliche  Geburtshulfe,  IV. 

Aufl.,  1901,  153-159. 
Frankenhauser.     Ueber  die  Herztone  der  Frucht  und  ihre  Benutzung  zur  Diagnose  des 

Geschlechts  derselben,  etc.     Monatsschr.  f.  Geburtskunde,  1859,  xiv,  161-174. 
Gardner.     The  Diagnosis  of  Early  Pregnancy.     Amer.  Jour,  of  Obst.,  1897,  xxxv,  54-63. 
Hicks.     On  the  Contraction  of  the  Uterus  throughout  Pregnancy.     Trans.  London  Obst. 

Soc,  1872,  xiii,  216-231. 
Kegaradec.     Memoire  sur  l'auscultation  appliquee  a  l'etude  de  la  grossesse.     Paris,  1822. 
Kennedy.     Observations  on  Obstetric  Auscultation.     New  York,  1847. 
Lourie.     De  l'influence  du  repos  sur  la  duree  de  la  grossesse.     These  de  Paris,  1899. 
Lowenhardt.     Die  Berechnung  und  die  Dauer  der  Schwangersehaft.     Archiv  f.  Gyn.r 

1872,  iii,  456-491. 
Mayor.     Quoted  in  Bibliotheque  universelle  de  Geneve,  November,  1818,  ix. 
Montgomery.     An  Exposition  of  the  Signs  and  Symptoms  of  Pregnancy,  2d  ed.,  London, 

1863. 
Reinl.     Prager  med.  Wochenschr.,  1884,  Nr.  26. 

Rotter.     Fiihlbares  Uteringerausch.     Archiv  f.  Gyn.,  1873,  v,  539-546. 
Sonntag.     Hegar's  Sign  of  Pregnancy.     Amer.  Jour.  Obst.,  1892,  xxvi,  145-157. 
Spiegelberg.     Lehrbuch  der  Geburtshulfe,  III.  Aufl.,  1891,  126,  127. 


CHAPTER    VIII 
THE  MANAGEMENT  OF  NORMAL  PREGNANCY 

From  a  biological  point  of  view  pregnancy  and  labour  represent  the 
highest  functions  of  the  female  productive  system,  and  a  priori  should 
be  considered  as  normal  processes.  But  when  we  recall  the  manifold 
changes  which  occur  in  the  maternal  organism,  it  is  apparent  that  the 
border-line  between  health  and  disease  is  less  distinctly  marked  during 
gestation  than  at  other  times,  and  derangements,  so  slight  as  to  be  of 
but  little  consequence  under  ordinary  circumstances,  may  readily  give  rise 
to  pathological  conditions  which  seriously  threaten  the  life  of  the  mother 
or  the  child,  or  both. 

It  accordingly  becomes  necessary  to  keep  pregnant  patients  under  strict 
supervision,  and  to  be  constantly  on  the  alert  for  the  appearance  of  unto- 
ward symptoms.  Ordinarily  the  services  of  an  obstetrician  are  engaged 
some  months  before  the  expected  date  of  confinement,  so  that  upon  him  de- 
volves the  duty  of  advising  the  patient  as  to  her  mode  of  life  during  the 
intervening  months.  Any  one  who  has  a  moderately  extensive  obstetrical 
practice  can  save  himself  some  little  trouble  by  having  cards  printed, 
which  briefly  outline  what  the  patient  is  expected  to  do,  and  in  which  are 
enumerated  the  various  abnormal  symptoms  which  may  occur  and  to  which 
the  physician's  attention  should  be  immediately  called. 

Unless  it  be  found  upon  inquiry  that  the  patient  has  been  leading  an 
ill-ordered  existence,  very  little  change  should  be  made  in  her  mode  of 
living,  and  she  should  be  encouraged  to  go  on  much  as  usual,  care  being 
taken  that  she  receives  the  proper  amount  of  amusement  and  diversion.  It 
is  the  duty  of  the  physician  to  gain  the  confidence  of  his  patient  and  en- 
courage her  to  come  to  him  whenever  anything  occurs  to  worry  her,  in- 
stead of  taking  advice  from  her  women  friends.  A  woman  in  her  first 
pregnancy  generally  stands  in  need  of  a  certain  amount  of  reassurance 
with  regard  to  the  dangers  of  parturition,  and  the  knowledge  that  she  is 
in  the  hands  of  a  competent  and  careful  physician  will  contribute  largely 
to  her  peace  of  mind  as  well  as  to  her  physical  well-being. 

Exercise. — During  pregnancy  the  woman  should  be  encouraged  to  take  as 
much  outdoor  exercise  as  possible,  though  in  individual  cases  it  is  often  diffi- 
cult to  specify  the  exact  amount — a  safe  rule  being  to  instruct  her  to  desist 
while  still  feeling  that  she  could  do  more  without  tiring  herself.  Exercise 
should  consist  of  walking  or  driving,  but  the  ordinary  sports  should  be  in- 
terdicted, though  sea-bathing  in  many  instances  is  very  beneficial.    "When 

175 


176 .  OBSTETRICS 

for  various  reasons  outdoor  exercise  cannot  be  taken,  massage  in  the  hands 
of  a  skilful  person  is  to  be  recommended.  In  the  later  months,  long 
journeys  should  not  be  undertaken  unless  absolutely  necessary,  and  driving 
over  rough  roads  should  be  avoided. 

Diet. — The  diet  should  be  abundant  and  nourishing,  and  ordinarily 
the  patient  should  be  allowed  to  continue  her  usual  customs,  but  should  be 
warned  to  abstain  from  very  highly  seasoned  or  indigestible  articles  of 
food.  In  slight  degrees  of  pelvic  contraction,  or  in  patients  who  have  pre- 
viously given  birth  to  excessively  heavy  children,  a  restricted  diet  may  be 
advisable  during  the  last  two  or  three  months.  Prochownick  pointed  out, 
and  his  experience  has  been  confirmed  by  Florschiitz  and  others,  that  a 
diet  poor  in  carbohydrates  and  fluids  exerts  a  marked  influence  upon  the 
weight  of  the  child  without~7)therwise  affecting  it,  and  in  not  a  few  cases 
these  precautionary  measures  may  obviate  a  difficult  delivery,  or  even  do 
away  with  the  necessity  for  the  induction  of  premature  labour. 

The  Bowels. — In  the  later  months  of  pregnancy  the  enlarged  uterus 
sometimes  interferes  with  the  normal  intestinal  peristalsis,  and  gives  rise 
to  more  or  less  marked  constipation.  Under  such  circumstances  care 
should  be  taken  that  the  bowels  are  moved  daily,  which  is  best  accom- 
plished by  the  administration  of  cascara  sagrada  or  pills  containing  aloin, 
belladonna,  and  strychnine.  The  use  of  active  cathartics  is  inadvisable, 
unless  their  employment  be  especially  indicated  in  certain  morbid  condi- 
tions. In  some  instances,  however,  the  judicious  administration  of  an  oc- 
casional dose  of  calomel  is  followed  by  marked  beneficial  results. 

Clothing. — The  physician  is  frequently  asked  concerning  the  clothing 
which  is  best  adapted  to  the  pregnant  state,  and  especially  whether  corsets 
should  be  worn  or  not.  Generally  speaking,  the  clothing  should  be  loose 
and  so  arranged  as  to  exert  as  little  pressure  upon  the  waist  as  possible; 
and  in  the  later  months  of  pregnancy,  at  least,  the  corset  should  either  be 
entirely  dispensed  with  or  replaced  by  a  loosely  fitting  corset-waist^  In 
multiparous  women,  when  the  abdomen  is  markedly  relaxed  from  previous 
childbearing,  the  wearing  of  an  abdominal  support,  either  an  ordinary 
Scultetus  bandage,  or  one  made  of  elastic  material,  adds  materially  to 
their  comfort.  When  varicose  veins  of  the  extremities  are  present,  the 
legs  should  be  bandaged  or  encased  in  elastic  stockings,  and  when  large 
varices  exist  about  the  vulva  the  patient  should  be  carrfcioned  concerning 
the  possibility  of  their  rupture. 

Sexual  Intercourse. — In  healthy  persons  sexual  intercourse  in  modera- 
tion usually  does  no  harm,  as  long  as  the  abdominal  enlargement  is  not 
too  great  to  make  it  inconvenient  for  the  patient.  But  where  there  is  a 
I  tendency  to  abortion  it  should  be  strictly  interdicted.  It  should  also  be 
positively  forbidden  in  the  last  month  of  pregnancy,  as  I  know  of  at  least 
one  case  in  which  a  severe  puerperal  infection  has  followed  coitus  during 
that  period. 

The  Breasts. — In  the  last  three  months  of  pregnancy  attention  should 
be  devoted  to  the  condition  of  the  breasts,  and  more  particularly  to  the 
nipples,  as  by  appropriate  preliminary  treatment  nursing  may  be  rendered 
easier,  and  the  occurrence  of  fissures  and  the  consequent  danger  of  mam- 


Till-:   MANAGEMENT  OF  NORMAL    PREGNANCY 


177 


Fig.  173. — Wooden  Nipple  Shield. 


mary  infection  in  greal  pari  prevented.  For  this  purpose  the  patient,  dur- 
ing the  last  two  months,  should  bathe  her  nipples  aighl  and  morning  with 
a  lotion  which  lends  to  make  the  skin  covering  them  more  resistant.  A 
saturated  solution  of  borax  or  boric  acid  in  50  per  cent  alcohol  will  answer 
the  purpose  very  well.  Where  the  nipples  are  small  it  is  advisable  to 
attempt  to  Lengthen  them  by  making  a  few  tractions  upon  them  night  and 
morning:  and  where  they  are  but  slightly  prominent  good  results  not 
infrequently  follow  the  wearing  of  a 
wooden  nipple  shield  (Fig.  L73)  for  a 
U'\v  hours  of  each  day.  1  know  of  no 
means,  however,  by  which  deeply  re- 
tracted nipples  can  be  made  serv- 
iceable. 

Urine. — Owing  to  the  frequency  of 
rem! I  disturbances  and  the  serious  con- 
sequences which  not  infrequently  re- 
sult from  them.,  the  urine  should  be 
carefully  examined  at  regular  inter- 
vals: once  a  month  for  the  first  seven 
months,  and  at  least  twice  a  month, 

and  preferably  every  week,  during  the  last  three  months  of  pregnancy.  It 
is  advisable  that  the  physician  should  not  only  arrange  definite  periods  at 
which  specimens  are  to  be  sent,  but  that  he  should  himself  make  a  note 
of  these  dates,  so  that  in  case  the  patient  becomes  careless  in  the  matter 
and  neglects  to  carry  out  his  directions,  he  can  remind  her.  Of  course  it 
may  be  very  plausibly  argued  that  the  patient  incurs  the  main  risk  from 
such  neglect;  but  the  prevention  of  a  single  death  from  eclampsia  will  amply 
repay  the  conscientious  physician  for  much  self-imposed  labour. 

The  urine  should  be. examined  not  only  for  the  presence  of  albumin 
and  sugar,  but  also  microscopically.  In  certain  cases  also  the  estima- 
tion of  the  total  urea  excreted  in  twenty-four  hours  is  of  extreme  impor- 
tance.    (See  Chapter  XXVI.) 

In  addition  to  giving  the  patient  the  advice  above  mentioned,  the  physi- 
cian should  also  impress  upon  her  the  importance  of  informing  him  at 
once  in  case  any  of  the  following  symptoms  he  noted:  a  scanty— 4ktf£_fif 
urine,  pprsistfmt  hpadnr-hp  disturbances  of  jvision,  swelling  of  thcJact  and 
f acej  any  loss  of  blood  no  matter  how  slight,  and  persistent  constipation. 
In  the  majority  of  cases  these  symptoms  are  of  secondary  importance,  but 
occasionally  they  serve  to  warn  us  of  the  imminence  of  some  serious  affec- 
tion, which  may  be  aborted  or  alleviated  by  appropriate  treatment. 

Preliminary  Examination. — Four  to  six  weeks  before  the  expected  date 
of  confinement  a  careful  examination  is  indispensable,  and  to  neglect  in 
this  respect  can  be  attributed  the  deaths  of  untold  numbers  of  women 
and  children.  Usually  this  can  be  made  much  more  conveniently  with 
the  patient  in  her  own  home  and  in  bed  than  at  the  physician's  office.  At 
this  time  the  general  condition  should  be  carefully  noted,  particular  atten- 
tion being  also  paid  to  the  measurements  of  the  pelvis  as  well  as  to  the 
presentation  and  position  of  the  child. 


178  OBSTETRICS 

But  unless  the  physician  fully  appreciates  the  importance  of  this  ex- 
amination, and  has  learned  to  look  upon  the  making  of  it  as  a  bounden 
duty,  he  may  sometimes  be  deterred  by  feeling  that  it  is  repugnant  to  the 
patient,  and  that  she  may  object  to  it  or  even  refuse  it.  My  experience, 
however,  has  always  been  that  a  few  words  of  kindly  explanation  soon 
smooth  away  all  such  difficulties;  and  when,  as  happens  fortunately  in 
the  vast  majority  of  cases,  after  the  examination  Ave  can  reassure  the 
woman  as  to  the  prospects  of  a  simple  and  safe  delivery,  she  will  feel 
amply  repaid  for  any  inconvenience  to  which  she  may  have  been  sub- 
jected. On  the  other  hand,  if  any  abnormality  is  present,  it  is  highly  de- 
sirable for  the  plrysician  to  know  of  its  existence  in  advance,  and  even 
although  he  may  not  always  deem  it  advisable  to  communicate  his  con- 
clusions to  the  patient  herself,  he  will  generally  do  well  to  inform  the 
husband  or  some  other  responsible  member  of  her  family  of  the  existing 
condition.  If,  however,  it  should  happen  that,  despite  the  exercise  of 
the  greatest  tact  on  the  part  of  the  physician,  and  his  insistence  that -such 
an  examination  is  a  necessity  for  her  own  sake,  the  patient  persists  in  her 
refusal,  the  former  has  no  alternative  but  to  decline  absolutely  to  attend 
the  case. 

The  first  point  in  the  preliminary  examination  is  careful  pelvic  mensura- 
tion, and  Dohrn  has  well  said  that  the  physician  who  neglects  pelvimetry 
is  comparable  to  one  who  attempts  to  treat  pulmonary  diseases  without 
the  aid  of  auscultation  and  percussion.  In  the  majority  of  instances  the 
external  measurements  are  quite  sufficient,  unless  they  indicate  the  pos- 
sibility of  some  pelvic  abnormality.  Generally  speaking,  if  the  measure- 
ments between  the  iliac  spines  and  crests  bear  an  approximately  normal  rela- 
tion to  one  another,  internal  pelvimetry  is  not  necessary  unless  Baude- 
locque's  diameter  is  18.5  centimetres  or  less,  or  unless  the  head  is  not 
engaged  in  primiparous  women,  or  the  patient  limps  or  presents  signs  of 
some  spinal  deformity.  In  the  latter  cases,  however,  the  pelvis  should  be 
measured  internally,  if  necessary  with  the  woman  under  the  influence  of  an 
anaesthetic;  otherwise  the  physician  will  be  unable  to  obtain  any  intelligent 
idea  of  the  existing  conditions  and  the  probable  outcome  of  the  labour. 
Armed  with  this  foreknowledge,  in  extreme  cases  he  will  be  prepared  at  the 
proper  time  to  suggest  the  induction  of  premature  labour,  or  to  keep  the 
patient  within  reach  of  a  competent  operator  who  will  be  ready  to  perform 
Cesarean  section.  It  is  an  indisputable  fact  that  the  generally  poor  results 
obtained  in  this  country  from  both  of  these  operations  are  directly  attribu- 
table to  the  neglect  of  pelvic  mensuration. 

After  measuring  the  pelvis,  the  abdomen  should  be  carefully  examined, 
the  duration  of  pregnancy  estimated,  and  the  existence  of  any  abnormality, 
as  hydramnios  or  twins,  noted;  after  which  the  position  and  presenta- 
tion of  the  child  should  be  determined  by  external  palpation,  according  to 
the  rules  which  will  be  given  later.  An  internal  examination  is  necessary 
only  in  those  eases  in  which  palpation  gives  uncertain  or  unsatisfactory 
results,  or  when  the  head  is  not  engaged  in  primiparous  women.  The 
physician  who  knows  how  to  utilize  all  the  resources  of  external  palpa- 
tion and  manipulation,  will  find  that  by  these  means  he  can  usually  not 


THE   MANAGEMENT  OF  NORMAL   PREGNANCY  17i» 

only  recognise  normal  and  abnormal  presentations  in  advance,  but  can  also 
convert  breech,  transverse,  or  face  presentations  into  those  of  the  vertex. 

In  the  rare  cases  in  which  vaginal  exploration  is  necessary  at  the  pre- 
liminary examination,  when  undertaken  prior  to  the  end  of  the  ninth 
lunar  month,  rigorous  hand  disinfection  is  not  necessary,  and  ihe  physician 
may  content  himself  with  the  use  of  a  nail-brush,  soap,  and  hot  water.  In 
the  last  month  of  pregnancy,  however,  the  hands  should  be  as  carefully  dis- 
infected as  at  the  time  of  delivery,  for  we  have  no  means  of  knowing 
exactly  when  labour  may  supervene,  and  our  neglect  may  occasionally  give 
rise  to  puerperal  infection. 

The  various  abnormalities  occurring  in  the  course  of  pregnancy  will  be 
considered  in  a  separate  chapter. 

LITERATURE 

Dohrn.     Leber  Beckenmessung.     Volkmann's  Sammlung  klin.  Vortrage,  Xr.  11. 
Florschutz.     Kritik  der  Versuche  durch  eine  bestimmte  Diat  der  Mutter  die  Gefahren 

der  Beckenenge  zu  umgehen.    D.  I.,  Giessen,  1895. 
Prochowxick.     Ein  Yersuch  zum  Ersatze  der  kunstlichen  Fruhgeburt.     Centralbl.  f. 

Gyn.,  1889,  577-581. 


CHAPTEE    IX 

PRESENTATION  AND  POSITION  OF  THE  FCETUS— METHODS 

OF  DIAGNOSIS 

Irrespective  of  the  relation  which  it  may  bear  to  the  mother,  the 
foetus  in  the  later  months  of  pregnancy  assumes  a  characteristic  posture, 
which  is  described  as  its  attitude  or  habitus;  and,  as  a  general  rule,  it  may 
be  said  to  form  an  ovoid  mass,  which  roughly  corresponds  with  the  shape 
of  the -uterine  cavity.  Thus,  it  is  folded  or  bent  upon  itself  in  such  a 
way  that  the  back  becomes  markedly  convex,  the  head  is  sharply  flexed  so 
that  the  chin  is  almost  in  contact  with  the  breast,  the  thighs  are  flexed 
over  the  abdomen,  the  legs  are  bent  at  the  knee-joints,  and  the  arches 
of  the  feet  rest  upon  the  anterior  surfaces  of  the  legs.  The  arms  are 
usually  crossed  over  the  thorax  or  are  parallel  to  the  sides,  while  the  um- 
bilical cord  lies  in  the  space  between  them  and  the  lower  extremities. 

This  attitude  is  usually  retained  throughout  pregnancy,  though  it  is 
frequently  modified  somewhat  by  the  movements  of  the  extremities,  and  in 
rare  instances  the  head  may  become  extended,  when  a  totally  different  pos- 
ture is  assumed.  The  characteristic  attitude  results  partly  from  the  mode 
of  growth  of  the  foetus,  and  partly  from  a  process  of  accommodation  be- 
tween it  and  the  outlines  of  the  uterine  cavity. 

Presentation. — By  this  term  is  understood  the  relation  which  the  long 
axis  of  the  foetus  bears  to  that  of  the  mother,  and  we  accordingly  distin- 
guish between  longitudinal  and  transverse  presentations.  X1  ot  infrequently 
during  pregnancy  the  foetal  may  cross  the  maternal  axis  at  an  angle,  and 
thus  give  rise  to  oblique  presentations;  but,  as  these  always  become  longi- 
tudinal or  transverse  during  the  course  of  labour,  they  are  not  considered 
as  distinct  varieties.  Longitudinal  presentations  are  by  far  the  most  fre- 
quent, occurring  in  99.5  per  cent  of  all  cases. 

Considerable  confusion  has  resulted  from  confounding  the  terms  pres- 
entation and  presenting  part.  By  the  latter  we  understand  the  portion 
of  the  foetus  which  is  felt  through  the  cervix  on  vaginal  examination, 
or  which  engages  at  the  superior  strait.  Accordingly,  when  the  long, 
axes  of  both  mother  and  foetus  are  in  the  same  direction,  the  presenting^ 
part  may  be  either  the  head  or  the  breech,  and  Ave  speak  of  cephalic  or 
breech  presentations  respectively.  When  the  foetus  lies  with  its  long  axis 
transversely  the  shoulder  is  the  presenting  part,  and  we  speak  of  shoulder 
presentations. 

Longitudinal  presentations  are  broadly  classified  as  normal,  and  trans- 
verse as  abnormal,  inasmuch  as  with  the  former  the  child  is  usually  delivered 
180 


PKKSKNTATloX    AND    POSITION   OP   THE   FCETUS 


L81 


1 1\  tin-  unaided  efforts  of  Nature;  whereas  if  the  Latter  persist  it  cannot  be 
born  spontaneously,  but  always  requires  the  aid  of  the  obstetrician.  These 
abnormal  presentations  will  be  considered  in  a  separate  chapter. 

Cephalic  presentations  are  divided  into  several  groups,  according  to  the 
relation  which  the  head  bears  to  the  body  of  the  child.    Usually  the  head 


Fig.  174.  Fig.  175.  Fig.  176.  Fig.  177. 

Figs.  174-177. — Showing  Difference  in  Attitude  of   Fcetus  m  Vertex,  Sinciput,  Brow,  and 

Face  Presentations. 


is  sharply  flexed,  so  that  the  chin  is  in  contact  with  the  thorax.  Under 
these  circumstances  the  vertex  is  the  presenting  part — vertex  presentation. 
More  rarely  the  neck  may  be  overextended,  so  that  the  occiput  and  back 
come  in  contact  and  the  face  is  felt  through  the  cervix — face  presentation. 
Again,  the  head  may  assume  an  intermediate  position  between  the  ex- 
tremes of  flexion  and  extension,  being  partially  flexed  in  some  cases, 
when  the  large  fontanelle  presents — sincipital  presentation;   or  partially 


Fig.  17S.  Fig.  179.  Fig.  ISO.  Fig.  181. 

Figs.  178-181. — Showing  Difference  in  Attitude  of  Fcetus  in  Frank  Breech,  Full  Breech, 

Foot,  and  Knee  Presentations. 


extended  in  other  cases,  so  that  the  brow  becomes  the  presenting  part — 
hrow  presentation.  The  last  two  are  not  usually  classified  as  distinct  vari- 
eties, as  they  are  usually  transient,  and  become  converted  into  vertex 
or  face  presentations  as  labour  progresses. 


182  OBSTETRICS 

When  the  child  presents  by  its  pelvic  extremity,  the  thighs  are  flexed 
and  the  legs  may  be  extended  over  the  anterior  surface  of  the  body — frank 
breech  presentation;  again,  the  thighs  may  be  flexed  on  the  abdomen  and 
the  legs  upon  the  thighs — breech  presentation;  or  the  feet  may  be  the  lowest 
part — foot  or  footling  presentation.  Occasionally  one  leg  may  assume  the 
position  which  is  typical  of  one  of  the  above-mentioned  presentations, 
while  the  other  foot  or  knee  may  present — incomplete  foot  or  knee  presenta- 
tion. As  the  mechanism  of  labour,  however,  is  essentially  the  same  in  all 
modifications  of  pelvic  presentations,  the  several  varieties  need  not  be 
•considered  separately. 

Position. — By  this  term  we  designate  the  relation  of  some  arbitrarily 
■chosen  portion  of  the  child  to  the  right  or  left  side  of  the  mother.  Accord- 
ingly, with  each  presentation  we  have  one  or  other  of  two  positions — 
right  or  left.  With  us  and  in  France,  the  occiput,  chin,  and  sacrum  are  the 
determining  points  in  vertex,  face,  and  breech  presentations '  respectively; 
while  in  Germany  the  objective  point  is  the  child's  back. 

Variety. — Furthermore,  for  the  purpose  of  still  more  accurate  descrip- 
tion, we  take  into  consideration  the  relationship  of  some  given  portion  of 
the  presenting  part  to  different  portions  of  the  mother's  pelvis.  Thus,  in 
each  position,  the  determining  portion  of  the  presenting  part  may  be  direct- 
ed towards  the  anterior,  transverse,  or  posterior  portion  of  either  side  of 
the  pelvis,  making  in  all  six  varieties  for  each  presentation.  But  as  the 
transverse  varieties  are  not  persistent,  and  represent  only  a  phase  in  the 
mechanism  of  labour,  they  need  not  be  taken  into  account. 

Nomenclature. — Unfortunately,  a  universal  nomenclature  for  designat- 
ing the  various  presentations  and  positions  has  not  as  yet  been  agreed 
npon,  and  the  methods  employed  vary  in  different  countries  and  even  in 
different  parts  of  the  same  country,  though  of  late  there  has  arisen  a 
greater  tendency  towards  uniformity. 

In  the  earlier  works  upon  obstetrics,  as  in  Boesslin's  Bosengarten 
(1513),  it  was  believed  that  the  child  might  assume  any  imaginable  posi- 
tion in  utero,  and  the  number  of  presentations  and  positions  was  limited 
only  by  the  ingenuity  of  the  writer.  More  accurate  observation  gradually 
•did  away  with  the  fanciful  forms,  but  even  as  late  as  1775  Baudelocque 
distinguished  94  different  presentations.  Mme.  La  Chapelle  (1821)  ma- 
terially simplified  the  subject,  and  the  classification  which  she  suggested 
•differs  but  little  from  that  employed  in  France  to-day,  which  has  been  best 
described  by  Farabeuf  and  Varnier. 

According  to  the  French  method,  vertex,  face,  and  breech  presentations 
are  designated  as  occipito-iliac  (0.  I.),  mento-iliac  (M.  I.),  and  sacro-iliac 
(S.  I.).  As  the  presenting  part  in  any  presentation  may  be  either  in  the 
left  or  right  position,  we  have  left  and  right  occipito-iliac,  left  and  right 
mento-iliac,  and  left  and  right  sacro-iliac  presentations,  which  in  an  abbre- 
viated form  may  be  written  L.  0.  I.  and  B.  0.  I.;  L.  M.  I.  and  B.  M.  I.; 
L/.  S.  I.  and  B.  S.  I.  Again,  as  the  presenting  part  in  each  position  may 
"be  directed  anteriorly,  transversely,  or  posteriorly,  we  may  have  six  vari- 
eties of  each  presentation,  though  the  transverse  modifications  are  fre- 
quently omitted.     Thus  we  have  the  following  classification: 


OI5STKTKICAL    NOMENCLATURE 


l  s:j 


I'lisition 


Vei  tex  presental  ions 


Left. 
Right. 


l'n-s.-ntali.'ii. 


Variety. 


Occipito-iliac. 


Anterior. 
Trans\  erse 

Posterior. 

Anterior. 
Transverse 

Posterior. 


Abbreviation. 


(L.  0.  I.  A.) 
(L.  0.  I.T.) 
I..  0.  I.  P.) 
(R.  0.  I.  A.) 
(R.  0.  I.T.) 
(R.  0.  I.  P.) 


Fig.  182.  Fig.  183. 

Figs.  182,  183. — Showing  Varieties  or  Vertex  Presentations. 


Face  presentations. 


Left. 

Mento-iliac. 

Anterior. 

(L.  M.  I.  A.) 

" 

" 

Transverse. 

<L.  M.  I.T.) 

(C 

a 

Posterior. 

(L.  M.  I.  P.) 

Right. 

it 

Anterior. 

(R.  M.  LA.) 

" 

Transverse. 

(R.  M.  I.  T.) 

" 

" 

Posterior. 

(R.  M.  I.  P.) 

Fig.  184.  Fig.  185. 

Figs.  184,  185. — Showing  Varieties  of  Face  Presentations. 


Breech  presentations. .. !        Left. 
Right. 


Sacro-iliac. 


Anterior. 
Transverse 

Posterior. 

Anterior. 
Transverse 

Posterior. 


(L.  S.  I.  A.) 
(L.  S.  I.  T.) 
(L.  S.  I.  P.) 
(R.  S.  I.  A.) 
(R.  S.  I.  T.) 
(R.  S.  I.  P.) 


Pig.  186.  Fig.  1-7. 

Figs.  1>i3.  15-7. — Showing  Varieties  of  Breech  Presentations. 


184  OBSTETRICS 

At  the  International  Medical  Congress  which  met  in  Washington  in 
1887,  an  attempt  was  made  to  secure  greater  uniformity  in  nomenclature. 
It  was  suggested  that  the  denomination  "  iliac  "  be  omitted  and  the  vari- 
ous presentations  designated  as  oceipito,  mento,  and  sacro  respectively, 
preceded,  as  the  case  might  be,  by  the  word  left  or  right  to  denote  the  posi- 
tion, and  followed  by  anterior',"  transverse,  or  posterior  to  indicate  the  vari- 
ety, the  following  abbreviations  being  employed:  L.  0.  A.,  L.  0.  P.,  E.  0.  A., 
E.  0.  P.;  L.  M.  A.,  L.  M.  P.,  E.  M.  A.,  E.  M.  P.;  L.  S.  A.,  L.  S.  P.;  E.  S.  A., 
E.  S.  P.  The  suggestion  was  quite  generally  adopted  in  this  country,  but 
failed  to  find  favour  abroad. 

The  older  nomenclature,  however,  seems  to  be  preferable  and  is  more 
accurate.  For  example,  when  one  speaks  of  a  left  occipito-iliac-anterior 
position,  there  is  absolutely  no  doubt  as  to  what  is  meant;  whereas,  on  the 
other  hand,  the  term  left  occipito-anterior  simply  describes  the  position 
of  the  head,  and  could  be  employed  equally  well  to  a  breech  or  vertex  pres- 
entation, were  it  not  arbitrarily  agreed  that  it  applied  only  to  the  latter. 

In  Germany  considerable  confusion  exists,  as  the  various  authorities 
still  employ  different  classifications.  Thus  Schroeder,  Olshausen  and  Veit 
do  not  distinguish  variety  at  all,  and  designate  the  position  according  to 
the  situation  of  the  back  of  the  child,  speaking  of  first  and  second  posi- 
tions according  as  the  back  is  directed  to  the  left  or  right  side  of  the 
mother  respectively.  Ahlfeld,  Doderlein,  and  others  employ  a  different 
nomenclature,  and  designate  our  L.  0.  I.  A.,  E.  0.  I.  A.,  E.  0.  I.  P.,  and 
L.  0.  I.  P.,  as  first,  second,  third,  and  fourth  positions  respectively.  The 
recent  exhaustive  article  of  Arthur  Muller  deals  fully  with  this  subject. 

The  nomenclature  which  we  have  adopted  presents  many  advantages 
over  the  German,  as  it  is  based  upon  the  relation  of  the  presenting  part  to 
the  maternal  pelvis,  and  enables  us  to  describe  with  accuracy  the  situation 
of  the  former  at  any  period  of  labour. 

Frequency  of  the  Various  Presentations  and  Positions. — According  to 
the  statistics  collected  by  Schroeder,  based  upon  several  hundred  thousand 
cases,  the  vertex  presents  in  95  per  cent,  the  face  in  0.6  per  cent,  and  the 
breech  in  3.11  per  cent,  transverse  presentations  occurring  in  only  0.56  per 
cent  of  all  cases.  Pinard  gives  95.5,  0.4,  3.3  and  0.8  per  cent  respectively. 
These  figures  apply  to  all  periods  of  pregnancy.  But  when  the  conditions 
at  full  term  alone  are  considered,  the  predominance  of  vertex  presentations 
becomes  still  more  marked,  as  they  are  met  with  in  96.97  per  cent  of  all 
cases;  while  breech  presentations  become  less  frequent,  and  occur  only  once 
in  62,  as  compared  with  once  in  30  labours  (1.77  and  3.3  per  cent)  re- 
spectively. 

It  is  usually  stated  that  about  70  per  cent  of  all  vertex  presentations 
occur  in  the  left,  and  only  30  per  cent  in  the  right  position.  Hecker 
estimated  their  relative  frequency  at  61.39  and  38.61  per  cent  respectively. 
Naegele  first  pointed  out  that  the  vertex  was  usually  directed  anteriorly  in 
left,  and  posteriorly  in  right  positions;  so  that  the  presenting  part  is 
usually  found  at  one  or  other  extremity  of  the  right  oblique  diameter  of 
the  pelvis,  owing  to  the  fact  that  the  left  oblique  diameter  is  materially 
encroached  upon  at  its  posterior  extremity  by  the  rectum. 


CAUSATION  OF  BEAD  PRESENTATIONS  1*5 

Reasons  for  the  Predominance  of  Head  Presentations. — Hippocrates 
recognised  the  overwhelming  frequency  of  head  presentations  al  the  end  of 
pregnancy,  bul  believed  thai  the  child  presented  by  the  breech  up  to  the 
seventh  month,  when  ii  suddenly  turned  and  presented  by  the  head,  the 
process  being  ot'ti'ii  expressed  by  the  French  term  culbute. 

As  a  result  of  the  more  frequent  examination  of  pregnant  women,  the 
error  of  the  Eippocratic  teachings  was  gradually  demonstrated,  so  that 
from  the  time  of  Smellie  and  Baudelocque  it  was  generally  believed  that 
head  presentations  predominated  throughout  all  periods  of  pregnancy, 
hut  became  more  frequent  in  the  later  months.  For  many  years  it  was 
taught  that  the  presentation  remained  constant  throughout  pregnancy, 
and  it  was  not  until  1861  that  Hecker  and.  others  demonstrated  that  it  was 
not  unusual  for  changes  of  position  to  occur  even  in  the  later  months. 
Finally,  it  is  now  universally  admitted  that  the  presentation  does  not  be- 
come definitely  established  until  the  presenting  part  enters  the  pelvic  canal. 

The  theories  put  forward  to  account  for  the  prevalence  of  head  presen- 
tations  are  divided  into  two  groups,  the  one  being  based  upon  gravita- 
tion, the  other  supposing  a  process  of  accommodation  between  the  foetus 
and  the  uterine  cavity. 

Thej/ ra  vita t ion  tli en ry  was  especially  advocated  by  Matthews  Duncan  and 
G.  Yeit,  both  of  whom  showed  that  a  foetus  recently  dead,  when  placed  in  a 
vessel  containing  a  solution  of  salt  having  about  the  same  specific  gravity  as 
itself  (1.050-1.055),  floated  with  its  head  and  right  side  downward.  This 
result  they  attributed  to  the  greater  specific  gravity  of  the  head,  together 
with  the  presence  of  the  liver  on  the  right  side.  Yeit  also  showed  that  head 
presentations  increase  in  frequency  with  the  advance  of  pregnancy,  but 
that  breech  presentations  were  noted  much  more  frequently  when  the 
child  was  dead.  This  he  attributed  to  the  fact  that  the  specific  gravity  of 
the  head  became  diminished  after  death. 

Furthermore,  it  was  pointed  out  that  since  the  axis  of  the  uterus,  with 
the  woman  in  the  upright  position,  forms  an  angle  of  about  35  degrees 
with  the  horizon,  provided  the  experiments  of  Duncan  and  Yeit  held  good, 
the  head  would  necessarily  sink  downward,  and  the  convex  back  of  the 
foetus  would  adapt  itself  to  the  concave  anterior  wall  of  the  uterus;  then, 
since  the  left  margin  of  the  latter  would  usually  be  directed  somewhat 
forward,  the  frequency  of  the  left  anterior  presentations  could  be  readily 
explained. 

Doubt  has  recently  been  cast  upon  the  conclusions  of  Duncan  and  Yeit 
by  Schatz,  who  maintains  that  although  their  results  were  perfectly  cor- 
rect when  experimenting  with  a  medium  of  the  same  specific  gravity  as  the 
foetus,  it  has  yet  to  be  demonstrated  that  they  hold  good  for  the  amniotic 
fluid,  which,  it  must  be  remembered,  possesses  a  specific  gravity  of  between 
1.008  and  1.009,  or  considerably  less  than  that  of  the  foetus.  Schatz  sus- 
pended a  recently  dead  foetus  from  the  pans  of  a  balance  in  a  solution 
of  salt  of  the  same  specific  gravity  as  the  amniotic  fluid,  and  found  that 
the  breech  had  a  greater  tendency  to  sink  down  than  the  head.  He  there- 
fore concluded  that  some  force  other  than  gravity  must  be  invoked  to 
explain  the  frequency  of  head  presentations. 


1 86  OBSTETRICS 

We  have  been  able  to  confirm  Schatz's  experiments,  and  found  that  the 
head  sank  downward,  as  described  by  Duncan  and  Veit,  when  the  specific 
gravity  of  the  medium  in  which  it  was  suspended  was  in  the  neighbourhood 
of  1.050.  But  on  gradually  lowering  it,  by  the  addition  of  more  water,  the 
head  slowly  rose  until  the  long  axis  of  the  child  became  horizontal,  and 
as  the  specific  gravity  approached  1.008-1.010,  the  breech  sank  downward, 
thus  showing  that  gravity  does  not  account  for  the  production  of  head  pres- 
entations; for  if  it  were  the  most  important  factor  concerned,  breech 
presentations  would  predominate  at  the  end  of  pregnancy.  As  this  is  not 
the  case,  some  other  influence  must  be  invoked  to  explain  the  prevalence 
of  head  presentations.  This  is  supplied  by  the  theory  of  accommodation 
advanced  by  Dubois,  Simpson,  and  Scanzoni,  according  to  which  they  are 
brought  about  by  a  process  of  accommodation  between  the  foetal  ovoid 
and  the  interior  of  the  uterine  cavity,  the  shape  of  the  latter  being  such 
that  the  foetus  is  most  comfortable  and  fits  it  more  accurately  when  pre- 
senting by  the  head.  They  held,  therefore,  that  as  soon  as  the  foetus"  came\ 
to  occupy  any  other  position,  its  cutaneous  surface  became  irritated,] 
whence  resulted  reflex  movements  of  the  extremities,  giving  rise  in  turn 
to  uterine  contractions,  which  tended  to  restore  the  head  presentation. 
Pinard  is  an  enthusiastic  advocate  of  this  theory. 

The  frequency  of  abnormal  presentations  in  the  early  months  of  preg- 
nancy, and  in  all  conditions  in  which  the  uterus  is  abnormally  distended 
by  an  excess  of  amniotic  fluid,  tends  to  substantiate  this  theory;  for  in  such 
cases  the  body  of  the  child  does  not  come  in  contact  with  the  uterine 
walls,  and  accordingly  the  conditions  necessary  for  the  production  of  the 
reflex  movements,  which  give  rise  to  accommodation,  are  entirely  lacking, 
and  gravity  alone  comes  into  play. 

An  exhaustive  consideration  of  the  various  older  theories  can  be  found 
in  the  excellent  monograph  of  Cohnstein  published  in  1868. 

Methods  of  Diagnosing  Position  and  Presentation  of  Postus. — The  diag- 
nostic methods  at  our  disposal  are  fourfold:  abdominal  palpation,  vaginal 
touch,  combined  examination,  and  auscultation. 

Obstetrical  Palpation. — Under  ordinary  circumstances  external  or  ab- 
dominal palpation  is  the  most  reliable  and  valuable,  and  I  should  unhesi- 
tatingly choose  it  were  I  restricted  to  the  employment  of  a  single  method 
of  examination.  In  trained  hands  it  enables  one  to  make  a  satisfactory 
diagnosis  without  danger  of  infection  and  with  the  least  possible  discom- 
fort to  the  patient,  and  it  is  not  going  too  far  to  say  that  its  popularization 
forms  one  of  the  greatest  advances  in  modern  obstetrics.  Under  these  cir- 
cumstances it  behooves  the  student  to  become  thoroughly  familiar  with  the 
proper  technique,  and  to  avail  himself  of  every  opportunity  to  become  pro- 
ficient in  the  various  manipulations. 

Although  crude  forms  of  abdominal  palpation  had  no  doubt  been  prac- 
tised from  the  earliest  antiquity,  just  as  they  are  still  employed  by  many 
of  the  aboriginal  peoples,  its  advantages  were  first  pointed  out  by  Eoederer, 
Wigand,  and  Hohl,  as  late  as  the  latter  part  of  the  seventeenth  and  the 
early  part  of  the  eighteenth  century.  Its  practical  importance,  however, 
was  not  generally  recognised  until  1878,  when  Pinard  published  his  work 


OBSTETRICAL   PALPATION  187 

tipon  the  subject,  after  which  the  method  became  popularized  in  France, 
but  was  not  employed  systematically  in  Germany  and  this  country  until 
Crede  and  Leopold  had  repeatedly  urged  its  value. 

In  order  to  obtain  satisfactory  results,  the  examination  should  be  made 
systematically  by  following  the  four  manoeuvres  suggested  by  Leopold. 
The  patient  should  be  on  a  hard  bed  or  sofa,  with  the  abdomen  bared,  or  at 
mosl  covered  with  a  thin  chemise.  During  the  first  three  manoeuvres,  the 
examiner  stands  at  the  side  of  the  bed  which  is  most  convenient  to  him, 
and  faces  the  patient,  but  reverses  his  position  and  faces  her  feel  for  the 
lasl  manoeuvre.     (See  Plates  X,  XI.  XII.  and  XIII.) 

First  Manoeuvre. — After  ascertaining  the  outlines  of  the  uterus,  the 
fundus  is  gently  palpated  with  the  tips  of  the  fingers  of  the  two  hands,  and 
the  foetal  pole  occupying  it  differentiated,  the  breech  giving  the  sensation 
of  a  large  irregularly  shaped,  nodular  body,  and  the  head  that  of  a  hard, 
round  object,  which  is  freely  movable  and  ballottable. 

5  cond  Manoeuvre. — Having  determined  which  pole  of  the  fcetus  lies 
at  the  fundus,  the  examiner  places  the  palmar  surface  of  his  hands  on 
either  side  of  the  abdomen  and  makes  gentle  but  deep  pressure.  On  one 
side  he  feels  a  hard  resistant  plane — the  back — and  on  the  other  numerous 
nodulations — the  small  parts.  In  women  with  thin  abdominal  walls  the 
legs  and  arms  can  readily  be  differentiated,  but  in  fat  persons  only  irregu- 
lar nodulations  can  be  felt.  In  the  latter  case,  or  when  a  considerable 
quantity  of  amniotic  fluid  is  present,  the  appreciation  of  the  back  can  be 
facilitated  by  making  deep  pressure  with  one  hand  while  palpating  with 
the  other.  After  determining  upon  which  side  the  back  is  situated,  we 
next  note  whether  it  is  directed  anteriorly,  transversely,  or  posteriorly, 
and  thereby  arrive  at  the  position  and  variety  of  the  presentation. 

Third  Manoeuvre. — The  examiner  grasps  the  lower  portion  of  the  ab- 
domen, just  above  the  symphysis  pubis,  between  the  thumb  and  fingers  of 
one  hand,  and  tries  to  decide  what  is  between  them.  If  the  presenting  part 
be  not  engaged,  a  movable  body  will  be  felt,  which  is  usually  the  head. 
The  differentiation  between  it  and  the  breech  is  made  as  at  the  fundus,  the 
former  being  appreciated  as  a  hard,  round,  ballottable  body.  If  the  pre- 
senting part  be  not  engaged,  this  practically  completes  the  examination,  as 
we  now  know  the  situation  of  the  head,  breech,  back,  and  extremities, 
and  all  that  remains  is  to  determine  the  attitude  of  the  head.  If  careful 
palpation  shows  that  the  greatest  cephalic  prominence  is  on  the  same  side 
as  the  small  parts,  we  know  that  the  head  is  flexed  and  that  the  vertex  is 
the  presenting  part;  but  when  the  reverse  is  the  case,  we  know  that  the 
head  is  extended  and  that  we  have  a  face  presentation.  On  the  other  hand, 
if  the  presenting  part  be  engaged,  this  manceuvre  simply  shows  that  the 
lower  pole  of  the  fcetus  is  fixed  in  the  pelvis,  and  the  details  concerning  it 
are  ascertained  as  follows: 

Fourth  Manceuvre. — The  examiner  faces  the  patient's  feet,  and  with  the 
tips  of  the  first  three  fingers  of  each  hand  makes  deep  pressure  in  the 
direction  of  the  axis  of  the  superior  strait.  If  the  head  presents,  he  finds 
that  one  hand  is  arrested  sooner  than  the  other  by  a  round  body — the 
cephalic  prominence:  while  the  other  hand  descends  deeper  into  the  pelvis. 


188  OBSTETRICS 

In  vertex  presentations,  the  prominence  is  on  the  same  side  as  the  small 
parts,  and  in  face  presentations  on  the  same  side  as  the  back.  Again,  the 
degree  of  ease  with  which  the  prominence  is  felt  indicates  the  extent  to 
which  descent  has  occurred.  In  breech  presentations,  the  information  ob- 
tained from  this  manoeuvre  is  not  so  definite  as  in  head  presentations.  In 
many  instances,  when  the  head  has  descended  into  the  pelvis,  the  anterior 
shoulder  of  the  child  can  be  readily,  differentiated  by  the  third  manoeuvre. 

This  method  of  examination  is  available  throughout  the  later  months 
of  pregnancy,  and  in  the  intervals  between  the  pains  at  the  time  of  labour. 
By  its  use  we  cannot  only  determine  the  presentation  and  position  of  the 
child,  but  also  obtain  important  information  as  to  the  extent  to  which 
the  presenting  part  has  descended  into  the  pelvis.  At  the  same  time  the 
size  of  the  child  can  be  roughly  estimated  and  the  second  foetus  mapped 
out  in  twin  pregnancy. 

During  uterine  contractions,  on  carefully  palpating  in  the  region  of 
the  internal  abdominal  ring,  one  can  often  distinguish  a  rounded  cord  on 
either  side — the  round  ligaments — from  which  important  information  may 
be  obtained.  In  the  first  place,  the  intensity  of  their  contraction  gives  us 
some  idea  of  the  manner  in  which  the  uterus  is  acting;  and  secondly,  by 
noting  their  course,  as  pointed  out  by  Palm  and  Leopold,  we  are  enabled 
to  diagnose  the  situation  of  the  placenta  in  about  88  per  cent  of  all  cases. 
When  the  round  ligaments  are  found  converging  towards  the  fundus  of  the 
uterus,  the  placenta  is  usually  situated  upon  the  posterior  wall,  whereas 
it  is  upon  the  anterior  wall  when  they  are  parallel  or  diverging. 

During  labour,  palpation  also  gives  us  valuable  information  concerning 
the  lower  uterine  segment;  when  there  exists  some  obstruction  to  the  pas- 
sage of  the  child,  the  contraction  ring  may  be  felt  as  a  transverse  ridge 
extending  across  the  lower  portion  of  the  uterus.  Moreover,  in  normal 
cases,  we  can  differentiate  by  palpation  between  the  contracting  body  of 
the  uterus  and  the  passive  lower  uterine  segment;  for  during  a  pain  the 
former  presents  a  firm,  hard  sensation,  while  the  latter  appears  elastic  and 
almost  fluctuant. 

Vaginal  Examination. — During  pregnancy  the  results  arrived  at  by 
vaginal  examination,  concerning  the  presentation  and  position  of  the  child, 
are  necessarily  somewhat  inconclusive,  as  one  is  obliged  to  palpate  the 
presenting  part  through  the  lower  uterine  segment.  During  labour,  on 
the  other  hand,  after  more  or  less  complete  dilatation  of  the  cervix,  im- 
portant information  may  be  obtained.  In  vertex  presentations,  the  posi- 
tion and  variety  are  determined  by  the  differentiation  of  the  various 
sutures  and  fontanelles;  in  face  presentations,  by  the  differentiation  of  the 
various  portions  of  the  face;  and  in  breech  presentations,  by  the  palpation 
of  the  sacrum  and  ischial  tuberosities. 

Under  the  most  favourable  circumstances,  the  information  to  be  de- 
rived from  vaginal  touch  alone  is  not  more  accurate  than  that  obtained  by 
abdominal  palpation,  and  in  vertex  presentations  the  fontanelles  are  not 
infrequently  mistaken  for  one  another,  and  occasionally  face  and  breech 
presentations  escape  differentiation.  Moreover,  in  the  latter  part  of  labour, 
after  the  formation  of  a  fluid  tumour  beneath  the  skin  covering  the  pre- 


VAGINAL  TOUCH 


ISO 


scnting  part — the  caput  succedaneum — detect  ion  of  the  various  diagnostic 
points  often  becomes  impossible. 

A  much  more  serious  objection,  however,  is  the  danger  of  puerperal 
infection,  no  matter  how  carefully  the  obstetrician  may  have  attempted  to 
disinfect  his  hands,  for  it  is  now  generally  admitted  that  absolute  hand 
disinfection  cannot  always  be  accomplished;  and  even  granting  that  the 
use  of  rubber  gloves  overcomes  this  difficulty,  the  gloved  fingers  may  still 
carry  pathogenic  micro-organisms  from  the  margins  of  the  vulva  up  into 
the  vagina,  and  thus  infect  the  patient.  Moreover,  vaginal  examination 
necessitates  exposure  of  the  patient,  and  subjects  her  to  more  or  less  serious 
inconvenience. 


Fig.  188. — Diagram  showing  Method  of  locating  Sagittal  Suture  on  Vaginal  Examination. 


Accordingly,  it  is  advisable  to  limit  its  employment  as  much  as  possible, 
and  in  normal  cases  to  do  away  with  it  altogether.  For  if  the  patient  has  a 
normal  pelvis,  and  we  find  by  the  fourth  manoeuvre  that  the  head  is  deeply 
engaged,  all  that  we  gain  by  vaginal  examination  is  information  as  to  the 
degree  of  dilatation  of  the  cervix,  and  this  does  not  counterbalance  the 
possible  danger  of  infection.  Accordingly,  vaginal  examination  becomes  ab- 
solutely necessary  only  in  the  few  cases  in  which  palpation  does  not  give 
satisfactory  results,  or  in  those  presenting  some  abnormality,  or  in  which 
the  course  of  labour  is  unduly  delayed.  Personally,  I  conduct  more  than 
50  per  cent  of  my  private  cases  by  palpation  alone,  and  do  not  make  a  vaginal 
examination  until  about  to  discharge  the  patient. 

In  attempting  to  diagnose  presentation  and  position  by  vaginal  ex- 
amination, it  is  advisable  to  pursue  a  definite  routine,  which  is  readily 
accomplished  by  three  manoeuvres. 

First  Manoeuvre. — After  most  careful  hand  disinfection  and  appropriate 
preparation  of  the  patient,  two  fingers  of  either  the  right  or  left  hand,  as 
best  suits  the  examiner,  are  introduced  into  the  vagina  and  carried  up  to 
the  presenting  part.  A  few  moments  suffice  to  determine  whether  it  is 
a  vertex,  face,  or  breech. 
13 


190 


OBSTETRICS 


Second  Manoeuvre. — If  the  vertex  be  presenting,  the  fingers  are  carried 
up  behind  the  symphysis  pubis,  and  are  then  swept  backward  over  the  head 
towards  the  sacrum.  During  this  movement  they  necessarily  cross  the 
sagittal  suture.  When  it  is  felt,  its  course  is  outlined,  and  we  know  that 
the  small  fontanelle  lies  at  one,  and  the  large  fontanelle  at  the  other  end 
of  it. 

Third  Manoeuvre. — We  then  attempt  to  determine  the  position  of  the 
two  fontanelles.  For  this  purpose  the  fingers  are  passed  to  the  anterior 
extremity  of  the  sagittal  suture,  and  the  fontanelle  there  encountered  is 
carefully  examined  and  identified;  then,  by  a  circular  motion,  the  fingers 
are  passed  around  the  side  of  the  head  until  the  other  fontanelle  is  felt  and 
differentiated.     By  this  means  the  various   sutures  and  fontanelles   are 


Fig.  189. — Diagram  showing  Method  of  Differentiating  between  the  Fontanelles. 


readily  located,  and  the  possibility  of  error  is  considerably  lessened.  In 
face  and  breech  presentations  it  is  still  further  minimized,  as  the  various 
parts  are  more  readily  distinguished. 

Combined  Examination. — By  combined  examination  we  understand  the 
introduction  of  two  fingers  of  one  hand  into  the  vagina,  and  the  applica- 
tion of  the  other  hand  over  the  lower  portion  of  the  abdomen.  This  meth- 
od is  rarely  employed  except  when  the  presenting  part  is  not  engaged, 
and  the  external  hand  is  used  to  fix  it  so  as  to  permit  the  internal  fingers 
to  explore  it  satisfactorily. 

Auscultation. — By  itself,  auscultation  does  not  give  very  important  in- 
formation as  to  the  presentation  and  position  of  the  child,  but  it  not  infre- 
quently re-enforces  the  results  obtained  by  palpation.  Ordinarily  the  heart 
sounds  are  transmitted  through  the  convex  portion  of  the  foetus,  which 
lies  in  intimate  contact  with  the  uterine  wall.  Accordingly  they  are  heard 
loudest  through  the  back  in  the  cervix  and  breech,  and  through  the 
thorax  in  face  presentations.  The  region  of  the  woman's  abdomen  in 
which  the  foetal  heart  is  heard  most  plainly  varies  according  to  the  pres- 


OBSTETRICAL   AUSCULTATION  191 

entation.  In  head  presentations  the  point  of  maximum  intensity  is  usu- 
ally midway  between  the  umbilicus  and  the  anterior  superior  spine  of  the 
ilium,  while  in  breech  presentations  it  is  usually  about  on  a  level  with  the 
umbilicus. 

Auscultation  frequently  gives  us  not  a  little  supplementary  aid  in  de- 
termining the  position  of  the  child.  Thus,  in  occipitoanterior  presenta- 
tions the  heart  is  usually  best  heard  a  short  distance  from  the  middle 
line;  in  the  transverse  varieties  it  is  heard  more  laterally,  and  in  the  pos- 
terior varieties  well  hack  in  the  patient's  flank.  Occasionally,  however, 
in  right  occipito-posterior  presentations,  the  information  gained  from  the 
position  of  the  foetal  heart  is  misleading,  and  may  give  rise  to  serious 
diagnostic  errors,  for  if  the  flexion  of  the  head  he  imperfect,  the  thorax 
may  become  convex,  and  the  heart  sounds  being  transmitted  through  it 
would  apparently  indicate  a  left  anterior  position. 

LITERATURE 

Ahlfeld.  Lehrbuch  der  Geburtshiilfe,  II.  Aufl.,  Leipzig,  1898. 
Baudelocque.  L'art  ties  accouchements.  Paris,  1789,  2me  ed. 
Cohnstein.     Die  Aetiologie  der  normalen  Kinderlage.     Monatsschr.  f.  Geburtsk.,  1868, 

xxxi,  141-193. 
Crede.     Gesunde  und  kranke  Wochnerinnen.     Leipzig,  1886,  80-81. 
Crede  und  Leopold.     Die  geburtshulfliche  Untersuchung.     Leipzig,  1892. 
Duderleix.     Leitfaden  filr  den  geburtshiilfliehen  Operationskurs.     Leipzig,  1893. 
Dubois.     Memoire  sur  la  cause  des  presentations  de  la  tete.     Mem.  de  PAcad.  de  Med., 

1833,  ii. 
Duncan.     The  Position  of  the  Foetus.     Researches  in  Obstetrics,  Edinburgh,  1868, 14-37 ; 

also  Edinburgh  Med.  and  Surg.  Jour.,  1855. 
Farabeuf  et  Varnier.     Introduction  a  l'etude  clinique  et  a  la  pratique  des  accouche- 
ments.    Paris. 
Hecker.     Klinik  der  Geburtshillfe,  Leipzig,  1861,  i,  17. 

Statistisches  aus  der  Gebaranstalt  Mlinchen.    Archiv  f.  Gyn.,  1882,  xx,  378-398. 
Hohl.     Die  geburtshulfliche  Exploration,  Halle,  1834,  ii,  144-166. 
International  Medical  Congress.    Uniformity  in  Obstetrical  Nomenclature.    American 

Jour.  Obst.,  1889,  xx,  1084-1086. 
La  Chapelle,  Madame.     Pratique  des  accouchements,  Paris,  1821,  i,  17-25. 
Leopold.     Die  Diagnose  des  Placentarsitzes  in  der  Schwangerschaft  und  wahrend  der 

Geburt.    Arbeiten  aus  der  Dresdener  Frauenklinik,  1895,  ii,  151-166. 
Leopold  und  Goldberg.    Ueber  die  Entbehrlichkeit  der  Scheiden-Ausspillungen,  etc.,  und 

iiber  die  grosstmogliche  Verwerthung  der  ausseren  Untersuchung  in  der  Geburtshillfe. 

Archiv  f.  Gyn.,  1891,  xl,  439-473. 
Leopold  und  Orb.     Die  Leitung  normaler  Geburten  nur  durch  aussere  Untersuchung. 

Archiv  f.  Gyn.,  1895,  xlix,  304-323. 
Leopold  und   Pantzer.     Die  Beschrankung  der  inneren  und  die  grosstmogliche  Ver- 
werthung der  ausseren  Untersuchung  in  der  Geburtshiilfe.     Archiv  f.  Gyn.,  1890, 

xxxviii,  330-366. 
Leopold   und   Sporlin.      Die  Leitung  der  regelmassigen  Geburten  nur  durch  aussere 

Untersuchung.     Archiv  f.  Gyn.,  1894,  xlv,  337-368. 
Muller,  A.     Ueber  die  Ursachen  der  Ungleichheit  und  Unklarheit  in   der  Benennung 

und  Eintheilung  der  Kindeslagen.     Monatsschr.  f.  Geb.  u.  Gyn.,  1900,  xii,  161-181, 

266-291. 
Naegele.     Die  Lehre  vom  Mechanisraus  der  Geburt,  Mainz,  1838,  10, 


192  OBSTETRICS 

Palji.     Ueber  die  Diagnose  des  Placentarsitzes  in  der  Schwangerschaft,  etc.    Zeitschr.  f. 

Geb.  u.  Gyn.,  1898,  xxv,  317-350. 
Pixard.     L'accommodation  foetale.     Traite  du  palper  abdominal.     Paris,  1878 ;  2rne  ed., 

1889. 
Roederer.     Elementa  artis  obstetriciae.     Goettingae,  1766. 
Scanzoni.     Lage  und  Haltung  des  Kindes  in  der  Gebarmutter.     Lehrbuch  der  Geb., 

II.  Aufl.,  Wien,  1853,  89-93. 
Schatz.     Ueber  den  Schwerpunkt  der  Frucht.     Centralbl.  f.  Gyn.,  1900,  Nr.  40, 1033-1036. 
Schroeder,  Olshausen  und  Veit.     Lehrbuch  der  Geburtshiilfe,  XIII.  Aufl.,  1899. 
Simpson.     Attitude  and  Positions  of  the  Foetus  in  utero.    Monthly  Journal  of  Med. 

Sciences,  ix,  1848-49. 
Smellie.    A  Treatise  on  the  Theory  and  Practice  of  Midwifery,  8th  ed.,  London,  1774. 
Veit,  G.     Die  Lagenverhaltnisse  bei  Friih-  und  Zwillingsgeburten.     Scanzoni"s  Beitrage, 

1860,  iv,  279-292. 
Wigand.     Die  Geburt  des  Mensehen.     Berlin,  1820,  ii,  99. 


PHYSIOLOGY    OF    LABOUR 

CHAPTEB   X 

THE   PHYSIOLOGY  AND   CLINICAL   COURSE  OF  LABOUR 

By  labour  we  understand  the  process  which  brings  about  the  separa- 
tion of  the  mature  or  nearly  mature  product  of  conception  from  the  in- 
terior of  the  uterus,  and  its  extrusion  from  the  maternal  organism,  whether 
the  birth  occurs  spontaneously  or  requires  external  aid. 

Cause  of  the  Onset  of  Labour. — From  time  immemorial  inquiring  minds 
have  sought  an  explanation  for  the  fact  that  labour  usually  ensues  about 
two  hundred  and  eighty  days  after  the  appearance  of  the  last  menstrual 
period,  but  thus  far  no  satisfactory  universal  cause  has  been  discovered. 
The  following  are  among  the  most  important  theories  which  have  been 
advanced  as  to  its  causation: 

1.  The  growing  irritability  of  the  uterus,  associated  with  an  increase  in 
the  frequency  and  strength  of  the  intermittent  contractions. 

2.  Inere-Hrig  flig+pntirm  of  the  nteru.g. 

3.  Dilatation  of  the  pp-rviv  by  the  presenting  part. 

4.  Increasing  distention  of  the  lower  uterine  segment,  with  pressure^ 
upon  the  neighbouring  nervous  structures^ 

5.  Changes  in  the  decidua — loosening,  thinning,  and  thrombosis. 

6.  Excess  of  carbon  dioxide  or  lack  of  oxygen  in  the  placental  blood, 
acting  on  a  centre  in  the  medulla. 

7.  The  circulation  of  festal  metabolic-  products  acting  upon  a  centre  in 
the  medulla. 

8.  ^Menstrual.  pfT-iodir-ify , 

9.  Heredity  anrl  habit 

10.  Senility  of  the  placenta,. 

11.  Physical  and  emotional  causes. 

1.  The  increasing  readiness  with  which  the  uterus  reacts  to  stimulation 
during  the  later  months  of  pregnancy  affords  abundant  evidence  of  its 
growing  irritability.  The  intermittent  contractions,  which  occur  at  inter- 
vals throughout  pregnancy,  come  on  more  frequently  at  this  time,  and 
with  so  much  greater  intensity  that  it  is  ofttimes  difficult,  in  the  last  few 
weeks  before  delivery,  to  distinguish  between  them  and  actual  labour 
pains. 

2.  Since  the  time  of  ^lauriceau  it  has  been  believed  that  the  uterus, 
when  distended  up  to  a  certain  point,  must  begin  to  contract  and  attempt 
to  empty  itself,  just  as  happens  in  the  case  of  any  other  hollow  viscus. 
This  presumption  is  supported  by  the  frequency  with  which  premature 

193 


194  OBSTETRICS 

labour  occurs  in  hydramnios  or  twin  pregnancies.  On  the  other  hand,  even 
an  extreme  distention  does  not  necessarily  give  rise  to  labour,  as  is  shown  by 
the  cases  of  prolonged  pregnancy  which  are  associated  with  large  children. 

3.  Galen  supposed  that  labour  resulted  from  gradual  dilatation  of  the 
cervix,  which  was  brought  about  by  the  pressure  of  the  presenting  part, 
and  the  view  has  had  numerous  adherents  ever  since.  That  the  condition 
of  the  cervix  is  not  the  sole  factor  is  shown  by  the  fact  that  in  a  certain 
number  of  instances,  especially  in  twin  pregnancies,  considerable  dilatation 
may  exist  for  days  or  even  weeks  before  the  onset  of  labour. 

4.  Keilmann  (1891)  and  Kniipffer  advanced  the  theory  that  the  onset 
of  labour  was  the  result  of  the  gradual  formation  of  the  lower  uterine  seg- 
ment, with  consequent  pressure  upon  the  surrounding  nervous  ganglia. 
Their  work  was  done  upon  the  bat  and  was  quite  convincing,  so  far  as 
that  animal  is  concerned.  But  inasmuch  as  their  conclusions  are  based 
upon  the  assumption  that  the  lower  uterine  segment  is  formed  from  the 
upper  portion  of  the  cervix,  it  cannot  be  accepted  for  human  beings  with- 
out hesitation. 

5.  Kaegele,  Simpson,  Scanzoni,  and  others  believed  that  the  decidua  in 
the  latter  weeks  of  pregnancy  underwent  fatty  degeneration,  which  re- 
sultecl  in  the  partial  separation  of  tne  ovum  and  its  practical  conversion 
into  a  foreign  body,  which  then  gave  rise  to  uterine  contractions.  More 
recent  investigations,  however,  have  shown  that  such  changes  occur  rarely, 
if  at  all. 

It  has  also  been  stated  that  the  septa,  by  which  the  glandular  spaces 
of,  the  compact  layer  of  the  decidua  are  bounded,  become  progressively 
thinner  in  the  later  months  of  pregnancy,  so  that  in  the  last  few  weeks 
very  slight  movements  suffice  to  bring  about  more  or  less  extensive  separa- 
tion of  the  ovum  from  the  uterine  wall.  No  doubt  the  septa  are  consider- 
ably thinner  in  the  later  than  in  the  earlier  months  of  pregnancy,  but  they 
are  not  torn  through,  as  a  rule,  until  after  the  expulsion  of  the  foetus. 

6.  Brown-Sequard,  in  1853,  demonstrated  that  an  excess  of  carbon 
dioxide  in  the  blood  led  to  energetic  uterine  contractions,  and  his  results 
have  been  confirmed  by  all  subsequent  investigators  (Keiffer).  In  spite  of 
this  fact,  however,  it  is  difficult  to  explain  why  there  should  be  a  marked 
and  sudden  increase  in  the  amount  of  carbon  dioxide  in  the  blood  sufficient 
to  give  rise  to  labour  at  the  appointed  time. 

Friedlander,  Leopold,  and  others  have  described  giant  cells  in  the 
depths  of  the  decidua.  These,  they  claimed,  were  associated  with  the  pro- 
duction of  thrombosis  in  many  of  its  vessels,  in  consequence  of  which  the 
placental  blood  became  loaded  with  carbon  dioxide,  which  in  turn  stimu- 
lated a  centre  in  the  medulla.  More  recent  work,  however,  has  shown  that 
the  giant  cells  play  little  if  any  part  in  the  production  of  the  thrombosis. 

7.  Spiegelberg  advanced  the  view  that  the  onset  of  labour  was  due  to 
foetal  rather  than  maternal  changes.  He  considered  that  the  mature  foetus 
needed  materials  for  its  .sustenance  other  than  those  furnished  by  the  pla- 
centa, and  that  as  a  result  of  insufficient  nutrition  certain. excrementitious 
substances  gained  access  to  the  maternal  circulation,  and  in  some  way 
stimulated  the  uterine  centre. 


CAUSE  OF  THE  ONSET  OF  LABOUR  195 

8.  Mende,  Tyler-Smith,  Lowenhardt,  Beard,  and  others  believe  that 
there  is  an  increased  tendency  towards  uterine  contractions  at  the  periods 
at  which  the  menstrual  flow  should  appear  if  the  patient  were  not  preg- 
nant, and  that  these  reach  their  acme  at  about  the  date  of  the  tenth  men- 
strual period  and  give  rise  to  labour. 

9.  Geyl  and  others  are  inclined  to  attribute  the  unset  of  labour  at  the 
usual  time  to  the  fact  that  Nature,  after  ages  of  experiment,  has  found  the  J 
end  of  the  tenth  month  to  be  the  most  suitable  time.     For  when  labour  \ 
occurs  at  a  later  period  it  is  usually  very  difficult  and  results  in  dead  chil-  ^ 
dren,  while  at   an   earlier  period  puny  children  are  born  which  usually 
perish  soon  after  birth. 

10.  Eden  and  the  writer  have  pointed  out  that  the  frequent  occurrence 
of  infarct  formation  in  the  placenta  at  term  must  be  regarded  as  evidence 
<>f  its  senility,  and  that  tins  change  is  analogous  to  the  obliteration  and 
atrophy  of  the  chorion  la?ve  at  an  earlier  period.  "Where  these  changes 
are  marked  the  nutrition  of  the  foetus  must  be  interfered  with,  and  it  is 
possible  that  certain  of  its  metabolic  products  may  result  in  stimulation  of 
the  uterine  centre. 

11.  It  is  also  a  well-known  fact  that  excessive  physical  exercise,  sudden  I 
jars  or  violence,  as  well  as  extreme  mental  emotion,  such  as  grief  and  I 
anger,  may  lead  to  the  termination  of  pregnancy.  / 

While,  then,  there  is  no  lack  of  theories  upon  the  subject,  at  the  same 
time  it  is  manifest  that  most  of  them  are  extremely  unsatisfactory,  and 
that  none  are  of  universal  application.  It  is  probable,  therefore,  that  in 
the  majority  of  cases  the  onset  of  labour  is  due  to  the  combination  of  a 
number  of  the  above-mentioned  causes,  and  that  only  some  slight  stimulus 
or  irritant  is  needed  to  set  it  in  progress.  On  the  other  hand,  it  is  possible 
that  some  law  ma}-  be  discovered  in  the  future  which  will  explain  the 
rhythm  of  the  various  sexual  functions  in  women — menstruation,  as  well 
as  the  onset  of  labour. 

Xearly  all  of  the  theories  to  which  reference  has  been  made  require  i 
the  intervention  of  the  nervous  system  for  the  ultimate  production  of  I 
labour.    It  is  generally  admitted  that  there  exists  in  the  medulla  a  centre  I 
for  uterine  contractions,  which  can  be  stimulated  by  an  excess  of  carbon  | 
dioxide  in  the  blood,  by  anaamia  and  the  presence  of  various  toxic  sub-|| 
stances;  and  it  seems  highly  probable  that  the  frequency  of  premature 
labour  in  cases  of  renal  insufficiency  and  eclampsia  may  be  due  to  the 
action  of  metabolic  poisons  upon  this  centre.    Furthermore,  it  seems  likely 
that  another  centre  exists  in  the  lower  portion  of  the  lumbar  cord,  which, 
however,  is  subsidiary  in  character,  inasmuch  as  labour  may  ensue  with- 
out its  intervention,  as  is  demonstrated  by  the  fact  that  normal  but  pain- 
less deliveries  have  occurred  following  the  severance  of  the  cord  above  the 
lumbar  region. 

According  to  Keiffer  the  uterus  has  a  threefold  nervous  supply,  which 
is  derived  principally  from  the  sympathetic  sysTeni,  partlyfrom  branches 
of  the  Inmhar  cord,  and  partly  from  its  intrinsic  nerves,  and  that  con- 
tractions may  result  from  the  stimulation  of  all  or  any  one  of  them. 

Keflex  contractions  of  the  uterus  can  be  induced  bv  the  stimulation  of 


I! 


196  OBSTETRICS 

the  central  end  of  any  spinal  nerve,  and  it  is  evident,  therefore,  that  the 
reflex  impulses  must  be  transmitted  through  the  cord.  The  only  excep- 
tion to  this  rule,  so  far  as  I  am  aware,  is  the  observation  of  Keiffer  con- 
cerning the  inhibitory  effect  of  stimulation  of  the  crural  nerve.  But,  on 
the  other  hand,  it  has  been  shown  by  the  experimental  work  of  Kein  that 
the  transmission  of  impulses  through  the  cord  is  not  absolutely  necessary 
to  the  production  of  labour.  He  isolated  the  uterus  in  rabbits  from  all 
connection  with  the  cerebro-spinal  system,  and  found  that  labour  pro- 
ceeded without  difficulty.  Similar  observations  have  been  made  upon 
human  beings  after  injuries  to  the  lower  portion  of  the  cord  (South, 
Benicke,  Lusk,  and  others). 

Oser  and  Schlesinger,  on4he  other  hand,  showed  that  pregnancy  and 
labour  might  go  on  without  interruption  and  end  with  normal  labour  after 
complete  severance  of  the  sympathetic  fibres  which  supply  the  uterus. 
Moreover,  Kehrer  has  demonstrated  that  the  organ  can  continue  to  con- 
tract after  its  removal  from  the  body,  provided  it  be  kept  moist  arid  suf- 
ficiently warm.  In  view  of  these  facts,  therefore,  it  must  be  admitted  that 
the  uterus  contains  an  intrinsic  nerve  supply,  more  or  less  similar  to  that 
found  in  the  heart  and  other  organs. 

Labour  Pains. — With  the  onset  of  labour,  the  painless  intermittent  con- 
tractions which  have  persisted  throughout  pregnancy  are  replaced  by  others 
of  increasing  intensity,  giving  rise  to  severe  pain,  and  bringing  about  the 
dilatation  of  the  cervix  and  the  expulsion  of  the  child  and  placenta. 
j  The  uterine  contractions,  just  as  those  of  all  other  non-striated  muscles, 
lare  independent  of  the  will  of  the  patient,  and  can  neither  be  increased 
por  diminished  in  frequency  by  her  volition.  But  at  the  same  time  they 
may  be  affected  by  the  emotions,  and  any  sudden  excitement  may  either 
check  them  or  cause  them  to  become  more  violent.  Thus,  it  is  a  matter  of 
common  observation  that  the  entrance  of  the  obstetrician  may  be  followed 
by  a  marked  lull  in  the  intensity  and  frequency  of  the  pains. 

The  contractions  begin  slowly,  gradually  reach  an  acme,  and  then 
gradually  diminish  in  intensity,  the  active  process  being  followed  by  a 
pause  of  some  length.  The  tracings  of  Schatz  and  Polaillon  show  that 
the  period  of  increase  occupies  the  greater  portion  of  the  pain,  and  that  its 
acme  is  of  very  short  duration.  In  the  lower  animals  which  possess  bicornu- 
ate  uteri,  the  contractions  are  distinctly  peristaltic  in  character;  but  the 
appearance  of  the  uterus  at  Cesarean  sections  does  not  appear  to  indi- 
cate that  such  is  the  case  in  human  beings,  although  Schatz  believes  that  a 
certain  amount  of  peristalsis  may  be  observed.  It  is  important  to  bear 
in  mind  that  labour  pains  are  effective  only  during  the  period  of  increase^ 
and  that  the  tightly  contracted  organ  is  worthless  from  a  mechanical  stand- 
point. 

These  uterine  contractions  are  nearly  always  accompanied  by  pain- 
ful sensations,  whence  the  term  "  labour  pains/'  although  the  amount  of 
suffering  varies  markedly  in  different  individuals.  The  pain  usually  begins 
in  the  sacral  region  and  then  slowly  passes  to  the  abdomen  and  down  the 
thighs.  In  the  egyly  stagesjrf  labour  it  is  due  almoslTexcTusively  to  pres- 
sure upon  the  nerve  endingsbetween  the  muscle  fibres;  but  in  the  later 


PHYSIOLOGY   OF   LABOUR   PAINS  107 

stages  it  is  augmented  by  the  overstretching  and  dilatation  of  the  soft 
parts,  and  becomes  most  marked  when  the  bead  distends  the  vulva  just  be- 
fore   its   birth.      Occasionally    the   suffering   experienced    during   labour    is 

very  slight,  and  in  rare  instances  the  process  may  he  almost  entirely  pain- 
less, even  though  the  patient  be  perfectly  conscious.  A  considerable  num- 
ber of  such  cases  have  been  collected  by  Coliez  in  a  recent  thesis.  Usually, 
however,  the  pains  are  very  severe,  and  not  infrequently  are  almost  insup- 
portable. 

At  the  onset  of  lahour  the  pains  come  on  at  intervals  of  from  fifteen 
to  thirty  minutes;  as  it  advances  they  gradually  become  more  frequent,  and 
eventually  occur  every  two  or  three  minutes.  Their  average  duration  is 
about  one  minute — thirty  to  ninety  seconds — though  suffering  is  not  experi-  \ 
enced  during  the  entire  contraction,  as  the  hand  placed  over  the  abdomen 
may  feel  the  uterus  becoming  hard  for  several  seconds  before  the  patient 
perceives  the  slightest  pain. 

Force  exerted  by  Labour  Pains. — On  this  point  there  has  been  a  good 
deal  of  misconception,  and  a  marked  tendency  towards  exaggeration  ap- 
pears in  the  writings  of  not  a  few  authors.  Thus  Sterne,  in  Tristram 
Shandy,  estimated  that  the  force  exerted  at  each  pain  during  labour 
amounted  to  470  pounds,  while  Professor  Haughton  put  it  at  577  pounds. 
Poppel,  Duncan,  Eibemont,  and  others  have  attempted  to  approximate  it 
by  trying  to  determine  the  force  necessary  to  cause  the  rupture  of  the 
membranes  outside  of  the  body.  This,  they  found,  varied  markedly,  the 
extremes  being  2,134  and  17,301  grammes.  In  100  experiments  Duncan 
placed  the  extremes  at  4  and  37.58  pounds  respectively,  with  an  average 
of  16.73  pounds. 

Joulin  and  other  observers  have  attempted  to  solve  the  problem  by 
calculating  the  force  exerted  in  forceps  deliveries.  Thus,  on  interpolating 
a  dynamometer  between  the  operator  and  the  ends  of  the  instrument,  it 
was  found  that  the  tractile  force  rarely  exceeded  80,  though  in  some 
cases  it  reached  100  pounds.  A  greater  force  than  this  cannot  come  into 
play,  as  it  has  been  shown  that  one  of  120  pounds  is  sufficient  to  tear  the 
child's  head  from  its  body. 

Schatz  approached  the  subject  in  a  more  accurate  manner,  and  inserted 
into  the  uterus  a  rubber  bag  which  was  connected  with  a  manometer.  In 
this  way  he  found  that  the  intra-uterine  pressure,  in  the  intervals  between 
the  contractions,  was  represented  by  a  column  of  mercury  20  millimetres 
high,  5  of  which  were  due  to  the  tonicity  of  the  uterine  walls  and  15  to 
its  contents.  During  the  pains,  however,  the  mercury  rose  considerably, 
reaching  a  height  of  from  80  to  250  millimetres,  which  corresponds 
to  a  force  of  84  to  27-J  pounds.  He  also  showed  that  the  force  exerted 
by  the  uterus  increases  markedly  when  the  foetus  is  partially  expelled 
from  it. 

A  rough  idea  may  also  be  gained  by  estimating  the  expenditure  of 
energy  necessary  to  restrain  the  head  as  it  emerges  from  the  vulva.  This 
rarely  exceeds  50  pounds,  although  the  obstetrician  not  infrequently  finds 
it  impossible  to  hold  it  back  at  the  acme  of  a  pain.  This  inability  is  in  great 
part  due  to  the  disadvantageous  manner  in  which  one  is  obliged  to  exert 


198 


OBSTETRICS 


one's  energy,  rather  than  to  the  actual  force  exerted  hy  the  uterine  and  ab- 
dominal contractions. 

Physical  Changes  during  Uterine  Contractions. — During  contraction 
the  uterus  undergoes  marked  changes  in  shape.  With  the  patient  on  her 
back,  the  organ  in  the  flaccid  state  rests  upon  the  vertebral  column,  and 
its  transverse  equals  or  exceeds  its  vertical  diameter.  But  when  it  con- 
tracts the  uterus  leaves  the  vertebral  column,  becomes  more  erect,  and 
pushes  the  anterior  abdominal  Avail  forward.  At  the  same  time  the  ver- 
tical increases  at  the  expense  of  the  transverse  diameter  (Fig.  190). 

The  dilatation  of  the  cervix  is  usually  brought  about  solely  by  the 
action  of  the  iiterine  muscles,  whereas  during  the  expulsion  of  the  child 
those  of  the  abdominal  wall  alsb  come  into  play.  During  the  second  stage 
the  patient  braces  Tier  body^against  some  fixed  object,  takes  a  deep  inspira- 
tion, closes  the  glottis,  and  makes  forcible  straining  movements  with  the 


Fig.  190. — Composite  Picture,  showing  Change  in  Shape  of  Abdomen  before  and  during  a 
Uterine  Contraction,  the  Darker  Outlines  indicating  Contraction. 


abdominal  and  respiratory  muscles.  By  these  means  the  intra-abdominal 
pressure  is  markedly  increased,  and  is  transmitted  directly  to  the  uterus. 
At  first  these  movements  are  voluntary,  but  as  labour  advances  they  pass 
beyond  the  control  of  the  will,  and  may  occur  even  with  the  patient  under 
profound  anaesthesia. 

The  abdominal  muscles,  therefore,  play  an  important  part  in  the  expul- 
sion of  the  child,  which  in  many  instances  makes  no  progress  without  their 
aid.  The  fact  that  spontaneous  labours  occasionally  occur  in  women  who 
are  paralyzed  from  the  waist  down  shows  that  their  action  is  not  indispen- 
sable in  every  case;  but,  on  the  other  hand,  the  application  of  low  forceps  is 
frequently  rendered  necessary  by  the  inability  of  the  abdominal  muscles  to 
do  their  work,  or  to  the  unwillingness  of  the  patient  to  bear  the  pain 
associated  with  their  employment. 

The  various  ligamentary  structures  connected  with  the  uterus  also  take 
part  in  the  contractions.    Of  these  the  most  important  are  the  round  liga- 


■     ci.IXHAL  COURSE  OF   LABOUR  190 

ments,  which  in  contracting  tend  to  draw  the  fundus  of  the  uterus  forward 
ami  tiTTTx  it  in  position.  They  can  be  readily  palpated  through  the  ab- 
dominal wall,  and  some  idea  of  the  intensity  of  the  uterine  contractions 
may  be  gained  from  their  consistency. 

The  pari  played  by  the  vagina  during  labour  is  almost  entirely  passive, 
and  it  is  only  after  the  expulsion  of  the  child  that  the  conn-action  of  the 
muscular  elements  in  its  walls  comes  into  play. 

The  general  arterial  tension  is  raised  during  the  labour  pains,  as  is 
indicated  by  the  flushed  look  of  the  patient.  The  pulse  becomes  acceler- 
ated during,  and  slower  in  the  intervals  between_the  pains.  It  is  also 
stated  thaFthe  temperature  rises  a  fraction  oiliiTcgree  during  each  pain, 
though  its  detection  requires  the  employment  of  very  accurate  thermom- 
eters. Respiration  becomes  slower  during  the  contractions,  more  rapid  in 
the  interval  between  them,  and  is  totally  abolished  during  the  expulsive 
pains  of  the  second  stage  of  labour. 

Clinical  Course  of  Labour. — Before  taking  up  the  consideration  of  the 
forces  concerned  in  the  expulsion  of  the  fcetus  and  the  mechanism  by 
which  it  is  accomplished,  it  is  advisable  for  the  student  to  follow  as  a 
spectator  the  course  of  parturition  in  a  primiparous  woman. 

Several  weeks  before  the  onset  of  labour  the  abdomen  undergoes  a 
marked  change  in  shape,  its  lower  portion  becoming  more  pendulous: 
whereas  in  the  neighbourhood  of  the  costal  margin  it  looks  decidedly  flat- 
ter. This  change  is  perceived  by  the  woman  herself,  who  feels  that  her 
waist  has  become  lower;  and  occasionally  it  occurs  so  suddenly  as  to  cause 
her  to  fear  that  something  has  given  way  inside  her  abdomen. 

Abdominal  palpation  at  this  period  shows  that  the  fundus  of  the  uterus 
has  descended  from  the  position  .which  it  occupied  at  the  ninth  month, 
and  resumed  that  of  the  eighth;  while  the  third  manoeuvre  shows  that  the 
•head,  which  was  previously  freely  movable,  has  become  fixed  in  the  superior 
strait.  These  changes  are  most  marked  in  primiparae,  and  frequently  do 
not  occur  in  multipara?  until  the  onset  of  labour. 

After  this  the  patient  experiences  considerable  relief  from  the  respira- 
tory disturbances  from  which  she  may  have  suffered;  but  at  the  same  time 
locomotion  may  become  more  difficult,  and  she  may  suffer  from  severe 
cramp-like  pains  in  the  lower  extremities  and  a  more  frequent  desire  to 
urinate. 

During  the  last  few  weeks  of  pregnancy  the  vaginal  secretion  is  in-' 
creased  in  amount,  the  labia  become  more  swollen  and  succulent,  gape 
more  or  less  widely,  and  not  infrequently  the  patient  may  experience  a  Tew 
transient  pains  for  a  number  of  days  before  confinement. 

For  purposes  of  description,  labour  is  divided  into  three  stages:  The 
first,  or  period  of  dilatation,  extends  from  the  commencement  of  labour 
until  the  cervix  is  completely  dilated.  The  second,  or  period  of  expulsion, 
extends  from  the  complete  dilatation  of  the  cervix  to  the  birth  of  the 
child;  while  the  third  stage,  or  placental  period,  lasts  from  the  birth  of  the 
child  to  the  extrusion  of  the  placenta. 

First  Stage. — About  the  end  of  the  tenth  lunar  month  the  primiparous 
patient  begins  to  experience  cramp-like  pains  in  the  lower  portion  of  her 


200 


OBSTETRICS 


abdomen,  which  she  frequently  mistakes  for  intestinal  colic.  At  first  these 
sensations  recur  only  at  long  intervals,  but  soon  are  felt  more  frequently. 
They  are  most  marked  in  the  lumbar  region  and  gradually  extend  towards 


Fig.  191. — Birth  of  Head,  Scalp  appearing  at  Vulva. 

the  abdomen  and  down  the  thighs.  As  the  pains  become  more  frequent 
they  likewise  increase  in  severity,  and  in  the  latter  part  of  the  first  stage  the 
patient  may  complain  bitterly,  and  often  seeks  to  ease  herself  by  making 
pressure  over  the  sacral  region. 

The  result  of  the  pains  in  this  stage  of  labour  is  to  bring  about  the 
dilatation  of  the  cervix,  and  as  it  slowly  yields  to  the  pressure  of  the  amni- 
otic fluid  contained  in  the  membranes,  slight  lesions  occur  about  its  mar- 
gins, which  are  manifested  by  a  small  admixture  of  blood  with  the  vaginal 
discharge — the  "  show."  During  this  period  the  patient  is  perfectly  com- 
fortable between  the  pains,  and  for  a  time  can  attend  to  her  ordinary 
avocations;  but  as  they  become  more  severe,  she  assumes  a  sitting  or  lean- 
ing posture,  and  frequently  gives  utterance  to  short,  sharp,  querulous  cries. 

After  the  pains  have  continued  for  from  twelve  to  fifteen  hours,  more  or 
less,  there  is  a  sudden  gush  of  clear  fluid  from  the  vagina,  which  in  the 
majority  of  cases  indicates  that  the  cervix  has  become  completely  dilated, 
and  that  the  membranes,  having  fulfilled  their  function  as  a  hydrostatic 
wedge,  have  ruptured.  The  amount  of  fluid  which  escapes  varies  accord- 
ing to  the  situation  of  the  point  of  rupture  and  the  position  of  the  pre- 
senting part.    In  vertex  presentations,  where  the  pelvis  is  normal,  the  cer- 


CLINICAL  COURSE  OF   LABOUR 


201 


vix  is  tamponed,  so  to  speak.  by  the  rounded  head,  and  only  the  portion  of 
liquor  amnii  which  lies  in  front  of  it  escapes.  On  the  other  hand,  if  the 
head  be  not  engaged,  or  there  be  some  disproportion  between  it  and  the 
presenting  part,  the  entire  amount  of  amniotic  fluid  may  escape.  But 
even  in  perfectly  normal  eases  a  small  quantity  gushes  out  with  each  pain. 

Not  infrequently  the  membranes  may  rupture  before  complete  dilata- 
tion of  the  cervix,  and  occasionally  even  before  the  onset  of  labour.  Under 
such  circumstances  the  presenting  part  has  to  act  as  a  dilating  wedge,  and 
as  it  fills  out  the  cervix  less  completely  and  accurately  than  the  unrup- 
tured membranes,  dilatation  proceeds  more  slowly.  These  are  instances 
of  what  are  commonly  known  as  dry  labours. 

Second  Stage. — For  a  short  time  after  rupture  of  the  membranes  there 
is  a  lull  in  the  labour  pains,  after  which  they  recur  with  increasing  fre- 
quency and  vigour,  and  compel  the  patient  to  take  to  her  bed,  where  if 
left  to  herself  she  assumes  a  crouching  or  squatting  posture.  During  this 
period  the  abdominal  muscles  are  brought  into  play.  At  first  the  patient, 
with  each  uterine  pain,  may  cause  them  to  contract  by  an  effort  of  her  will. 
Later,  however,  this  act  becomes  involuntary,  and  she  is  usually  unable  to 
resist  bearing  down.    At  the  onset  of  the  pain  she  braces  her  feet  against 


r 


Fig.  192. — Birth  of  Head,  Vulva  partially  Distended. 


some  solid  object,  takes  a  deep  inspiration,  and  brings  her  abdominal  and 
respiratory  muscles  into  active  play,  her  efforts  being  accompanied  by  a 
characteristic  grunting  sound.    At  the  same  time  her  face  becomes  mark- 


202 


OBSTETRICS 


edly  congested,  and  in  the  later  stages  of  labour  covered  with  sweat.  As 
the  pain  passes  off,  the  glottis  is  opened  and  respiration  re-established,  the 
same  phenomena  being  repeated  as  soon  as  another  contraction  comes  on. 


Fig.  193. — Birth  of  Head,  Vulva  completely  Distended. 

It  is  during  this  period  that  the  child  descends  through  the  pelvis. 
After  expulsive  pains  have  continued  for  about  an  hour  the  patient  ex- 
periences a  marked  desire  to  go  to  stool,  which  indicates  that  the  head 
has  passed  into  the  pelvic  cavity  and  is  pressing  upon  the  rectum.  In  a 
short  time  the  pelvic  floor  may  be  seen  to  bulge  with  each  pain,  and  a 
little  later  the  scalp  of  the  foetus  may  be  detected  through  the  slit-like 
vulval  opening.  With  each  subsequent  pain  the  peringeum  bulges  more  and 
more,  and  the  vulva  becomes  more  and  more  dilated  and  distended  by  the 
head,  being  gradually  converted  into  an  ovoid,  and  at  last  into  an  almost 
circular  opening.  With  the  subsidence  of  each  contraction,  it  becomes 
smaller  and  the  head  recedes  from  it,  to  advance  again  with  the  next  pain. 

As  labour  progresses  the  perinamm  becomes  still  more  distended  and 
thinner,  especially  in  its  anterior  portion;  so  that  eventually  its  frenulum 
does  not  exceed  a  piece  of  paper  in  thickness,  and  looks  as  if  it  would  rup- 
ture with  each  pain.  At  the  same  time  the  anus  becomes  markedly  stretched 
and  protuberant,  and  the  anterior  wall  of  the  rectum  protrudes  through  it. 
By  this  time  the  perinamm  has  become  converted  into  a  deep  gutter,  6  to  7 
centimetres  long,  at  the  end  of  which  is  the  vulval  opening,  which  looks 
almost  directly  upward  and  is  distended  by  the  head  of  the  child,  the 


CLINICAL  COURSE   OF   LABOUR 


203 


occiput  being  pressed  firmly  against  the  symphysis  pubis.  The  distention 
of  the  vulva  is  most  marked  at  its  perineal  margin,  and  only  slight  at  its 
lateral  portions. 

The  head  advances  a  little  with  each  pain  and  recedes  in  the  intervals 
between  them.  This  continues  until  the  parietal  bosses  become  engaged  in 
the  vulva,  when  further  recession  becomes  impossible,  and  with  the  next 
two  or  three  pains  it  is  rapidly  expelled  by  a  movement  of  extension,  the 
base  of  the  occiput  rotating  around  the  lower  margin  of  the  symphysis  pubis 
as  a  fulcrum,  while  the  bregma,  brow,  and  face  successively  pass  over  the 
frenulum.  In  the  majority  of  cases  the  perinaeum  is  unable  to  withstand  the 
strain  to  which  it  is  subjected,  and  tears  in  its  anterior  portion,  though 
usually  only  to  a  slight  extent. 

Immediately  after  its  birth  the  head  falls  backward,  so  that  the  face 
comes  almost  in  contact  with  the  anus.  In  a  few  moments  the  occiput 
turns  towards  the  one  or  other  thigh,  and  eventually  the  entire  head  assumes 
a  transverse  position.  This  is  known  as  external  rotation  or  restitution, 
and  serves  to  bring  the  bisacromial  diameter  of  the  child  into  relation 
with  the  antero-posterior  diameter  of  the  pelvic  outlet. 


Fig.  194. — Bikth  of  Head,  showing  Delivery  by  Extension. 

At  this  time  the  perina?itm  is  quite  tightly  retracted  around  the  neck  of 
the  infant,  whose  face  in  consequence  becomes  markedly  congested,  so  that 
the  inexperienced  obstetrician  often  has  an  almost  uncontrollable  desire 
to  seize  the  head  and  to  extract  the  child  by  traction  upon  it.    This,  however, 


204 


OBSTETRICS 


is  usually  unnecessary,  for  the  next  pain  forces  the  anterior  shoulder  down 
under  the  symphysis  pubis,  where  it  becomes  fixed;  while  the  posterior 
shoulder  emerges  over  the  anterior  margin  of  the  perinasum,  after  which  the 
body  of  the  child  is  rapidly  expelled  by  a  movement  of  lateral  curvature, 
corresponding  to  the  axis  of  the  birth  canal. 


Fig.  195. — Birth  of  Head,  Face  failing  Backward  towards  Ants. 

Immediately  following  the  child  comes  a  gush  of  amniotic  fluid,  which 
represents  the  portion  which  did  not  escape  at  the  time  of  rupture  of  the 
membranes,  and  is  more  or  less  tinged  with  blood. 

In  primiparous  women  the  second  stage  of  labour  usually  lasts  about 
two  hours,  and  a  much  shorter  period  in  multlparous  women,  in  whom  two 
or  three  pains  not  infrequently  suffice  for  the  completion  of  the  period  of 
expulsion. 

Third  Stage. — For  a  few  minutes  after  the  birth  of  the  child  there  is 
a  cessation  of  the  uterine  contractions,  and  the  patient  experiences  a 
marked  sense  of  relief.  On  glancing  at  the  abdomen  it  is  seen  that  the 
uterus  has  become  much  smaller  and  forms  a  solid  tumour  which  barely 
reaches  the  umbilicus.  After  a  longer  or  shorter  period  the  uterine  con- 
tractions commence  once  more  and  the  woman  begins  to  bear  down;  a  few 
moments  later  the  fundus  of  the  uterus  may  be  seen  to  rise  up  for  several 
centimetres,  and  a  slight  tumefaction  appears  immediately  above  the  sym- 
physis pubis.  (See  Figs.  284  and  285.)  This  indicates  that  the  placenta  has 
become  separated  from  the  interior  of  the  uterus  and  is  now  in  the  lower 


DURATION   OF    LABOUR 


L'".-, 


uterine  segnienl  or  the  upper  portion  of  the  vagina.  From  this  position  it 
is  expelled  by  the  action  of  the  abdominal  muscles,  the  time  varying  accord- 
ing to  the  efficiency  of  their  contraction.  In  some  women  the  entire 
placental  period  may  be  terminated  spontaneously  within  a  Hew  minutes 
after  the  birth  of  the  child,  while  in  others  the  placenta  may  remain  in  the 
lower  uterine  segment  for  hours  unless  forced  from  it  by  proper  manipula- 
tion on  the  part  of  the  obstetrician. 

During  the  third  stage  there  is  nearly  always  a  slight  amount  of  haem- 
orrhage, which  in  normal  cases  amounts  To  300  or  400  cubic  centimetres. 
Not  infrequently  the  patient  may  have  a  chill  during  this  period,  or  imme- 
diately after  its  completion.  This,  although  it  may  appear  somewhat 
alarming,  in  itself  has  no  significance,  as  it  is  merely  a  vaso-motor  phe- 
nomenon. 

Duration  of  Labour. — The  duration  of  labour  presents  considerable 
individual  variations,  and  is  usually  about  six  hours  longer  in  primipara? 
than  in  multipara?.  Generally  speaking,  the  average  for  the  former  is 
about  eighteen  hours,  of  which  sixteen  are  occupied  by  the  first,  one  and 


Fig.  196. — Birth  of  Head,  External  Rotation. 

three  quarters  to  two  by  the  second,  and  a  quarter  to  a  half  hour  by  the 
third  stage  of  labour;  for  the  latter  it  is  about  twelve  hours,  eleven  of  which 
are  occupied  by  the  first,  and  one  by  the  second  stage. 

According  to  G-.  Yeit,  the  average  duration  of  labour  is  twenty  hours 
for  primiparas  and  twelve  for  multiparas;  according  to  Spiegelberg,  seven- 
14 


206  OBSTETRICS 

teen  and  twelve  hours  respectively;  while  Varnier,  from  the  records  of 
2,000  cases,  one  half  of  which  were  primiparas,  estimates  it  at  thirteen 
and  a  half  and  seven  and  a  half  hours  respectively;  the  second  stage 
lasting  seventy-five  minutes  in  the  former,  and  thirty-five  minutes  in  the 
latter. 

The  slower  course  of  labour  in  primiparse  is  due  to  the  resistance 
offered  by  the  soft  parts.  Occasionally  labour  may  be  extremely  rapid,  and 
even  in  primiparge  the  entire  process  is  not  very  infrequently  completed 
within  a  few  hours;  while,  on  the  other  hand,  a  duration  of  twenty-four 
to  thirty-six  hours  or  even  longer  is  not  unusual. 

Labour  is  usually  more  prolonged  in  elderly  than  in  young  primiparse 
— that  is,  after  the  thirtieth  year.  According  to  Ahlfeld,  it  averages  seven 
hours  longer  in  the  former,  though  Varnier  states  that  the  difference  is 
very  much  less.  At  the  same  time  the  latter  author  points  out  that  forceps 
are  much  more  frequently  required  in  older  primiparse,  being  applied  in 
25  per  cent  and  1.6  per  cent  of  the  cases  respectively,  thus  indicating  that 
labour  would  have  lasted  much  longer  had  it  not  been  terminated  by 
operative  means. 

It  is  generally  stated  that  the  majority  of  women  fall  into  labour 
in  the  early  evening,  and  that  delivery  occurs  most  frequently  between  the 
hours  of  2  and  4  a.  m. 

LITERATURE 

Ahlfeld.     Die  Geburten  alterer  Erstgeschwangerten.     Archiv  f.  Gyn.,  1872,  iv,  510-520. 

Beard.     The  Span  of  Gestation  and  the  Cause  of  Birth.     Jena,  1897. 

Benicke.     Vier  Falle  von  Geburtscomplication  durch  seltene  Erkrankungen  der  Mutter. 

Zeitschr.  f.  Geb.  u.  Gyn.,  1877,  i.  24-72. 
Brown-Sequard.     Experimental  Researches  applied  to  Physiology  and  Pathology,  1853, 

117. 
Coliez.     Quelques  considerations  medico-legales  sur  les  accouchements  inconscients  et 

sans  douleur.     These  de  Paris,  1899. 
Duncan.     A  Contribution  to  the  Dynamics  of  Labour.     Researches  in  Obstetrics,  Edin- 
burgh, 1868,  229-333. 
Eden.    A  Study  of  the  Human  Placenta.     Jour.  Path,  and  Bacteriology,  1897,  iv,  265-282. 
Geyl.     Leber  die  Ursache  des  Geburtseintrittes.     Archiv  f.  Gyn.,  1881,  xvii,  1-18. 
Joulin.     Memoire  sur  l'emploi  de  la  force  en  obstetrique.     Arch.  gen.  de  med.,  fev.  et 

mars,  1867. 
Kehrer.     Die  Zusammenziehungen  der  glatten  Genitalmuskulatur,  etc.     Beitrage   zur 

vergleich.  und  exp.  Geburtskunde,  1867,  Heft  II,  41-50. 
Keiffer.     Recherches  sur  la  physiologie  de  l'uterus,  Bruxelles,  1896. 
Keilmann.     Zur  Klarung  der  Cervixfrage.     Zeitschr.  f.  Geb.  u.  Gyn.,  1891,  xxii,  106-178. 
Knupffer.     Ueber  die  Ursache  des  Geburtseintrittes,  etc.     D.  I.,  Dorpat,  1892. 
Leopold.     Studien  liber  die  Uterusschleimhaut,  etc.     Archiv  f.  Gyn.,  1877,  xi,  443-500. 
Lowenhardt.     Die  Berechnung  und  die  Dauer  der  Schwangerschaft.     Archiv  f.  Gyn., 

1872,  iii,  356-391. 
Lusk.     The  Science  and  Art  of  Midwifery.     New  edition,  1895,  126. 
Mauriceau.     Traite  des  maladies  des  femmes  grosses,  etc.,  6me  ed.,  1721.  203. 
Mende.     Handbuch  der  gerichtlichen  Medicin,  1821,  ii,  303. 
Naegele.     Versuche  eines  Systems  der  Geburtshillfe,  1812,  97. 
Oser  und  Schlesinger.     Exper.  Untersuchungen  tiber  Uterusbewegungen.     Strieker's 

med.  Jahrbucher,  1872,  57. 


THE   PHYSIOLOGY   AND   CLINICAL  COURSE  OF   LABOUR         207 

Polaillo.v.     Recberches  sur  la  pbysiologie  de  1' uterus  gravide.     Paris,  1880. 
Poppel.     Ueber  die  Resistenz  der  Eihiiute.     Monatsschr.  f.  Geburtskunde,  1863,  xxii.  1-15. 
Rein.     Beitrag  zur  Lehre  von  der  Innervation  des  Uterus.     Pfliiger's  Archiv,  xxiii,  68. 
Rooth.     Pari  urition  during  Paraplegia.     Trans.  London  Obst.  Si    ..  l  V!'T,  xxxix.  191-200. 
Si  lnzoni.     [Jrsache  der  Geburt.     Lebrbucb  der  Geburtshulfe,  II.  Aufl.,  1853,  165-167. 
Schatz.     Beitrage  zur  physiologischen  Geburtskunde.     Archiv  f.  Gyn.,  1872,  iii.  •'jx-144. 
(Jeber  die  Formen  der  Wehencurve  und  iiber  die  Peristaltik  des  menschlichen  Uterus. 

Archiv  f.  Gyn.,  1886,  xxvii,  284-292. 
Ueber  die  Entwickelung  der  Krafl   des  Uterus  im  Verlaufe  der  Geburt.     Verh.  d. 

deutscben  Gesell.  fiir  Gyn.,  1895,  531-542. 
Spiegelberg.     I >i«--  Dauer  dor  Geburt.     Lehrbuch  der  Geburtshulfe,  II.  Aufl.,  l^ijl.  146. 
Spiegelberg- Wiener.     Lehrbuch  der  Geburtshulfe,  II.  Aufl..  1891,  lo4-iyT. 
Tyler-Smith.    The  Principles  and  Practice  of  Obstetrics.     London,  1s4'j. 
Yarn  ilk.     Combien  de  temps  dure   l'accouchement.     L'Obstetrique  journaliere,   1900, 

174-181. 
Veit.    Beitrage  zur  geburtshulflichen  Statistik.     Monatsschr.  f.  Geburtskunde,  1854,  v, 

344-381;  1855,  vi,  101-132. 
Williams.  J.  Whitrioge.     The  Frequency  and  Significance  of  Infarcts  of  the  Placenta. 

Araer.  Jour,  of  Obst..  1900,  xli,  No.  6. 


CHAPTEE  XI 


PHYSIOLOGY  OF  LABOUR   {Continued) 


THE    FORCES    CONCERNED    IN    LABOUR 

The  Cervix  in  the  Later  Part  of  Pregnancy. — On  vaginal  examination 
in  the  later  months  of  pregnancy,  the  cervix  is  found  to  be  much  softer 
and  somewhat  broader  than  in  the  non-pregnant  condition.  At  the  same 
time  it  usually  gives  the  impression  of  being  considerably  shortened,  espe- 
cially in  its  anterior  portion.  This  condition  led  Mauriceau,  Boederer, 
and  nearly  all  of  the  earlier  authorities  to  believe  that  from  the  fifth 
month  onward  the  upper  portion  of  the  cervix  gradually  became  obliterated 
and  contributed  to  the  enlargement  of  the  uterine  cavity,  that  which  was 
left  at  the  end  of  pregnancy  representing  merely  its  inferior  end. 

Stoltz,  in  1826,  demonstrated  the  incorrectness  of  this  doctrine,  and 
stated  that  the  shortening  was  only  apparent,  and  was  brought  about  by 
a  fusiform  dilatation  of  the  cervical  canal  which  resulted  in  the  approach 
of  the  internal  to  the  external  os.  He  believed  that  the  cervix  retained 
its  integrity  until  about  two  weeks  before  the  onset  of  labour,  when  the 
canal  slowly  became  obliterated  and  came  to  form  part  of  the  uterine 
cavity.  Matthews  Duncan  accepted  these  views,  but  pointed 
out  that  they  had  been  anticipated  by  the  anatomical  work 
of  Yerhegen,  De  Graaf,  and  Weitbrecht  (1710-'50).  At  the 
same  time  he  insisted  upon  certain  modifications,  holding 
that  the  cervical  canal  remained  practically  unchanged  until 
the  onset  of  labour.  His  statements  soon  received  abundant 
confirmation  from  the  observations  of  Hoist,  Muller,  Lott, 
Taylor,  Lusk,  and  many  other  investigators. 

Muller  pointed  out  that  the  apparent 
shortening  of  the  cervix  was  due  to  the 
marked  anteflexion  of  the  uterus  and  the 
depression  of  the  anterior  fornix  of  the 
vagina  by  the  presenting  part,  to  which 
should  be   added  the   increased  succu- 
lence of  the  entire  genital  tract.    He  also 
stated  that  the  finger,  at  the  end  of  pregnancy,  could  be  introduced  into  the 
canal  for  a  distance  of  2.5  to  3  centimetres  before  it  was  arrested  by  the 
internal  os.     His  conclusions  were  verified  by  further  clinical  observation, 
so  that  it  is  now  generally  admitted  that  in  the  great  majority  of  cases  the\ 
208  ' 


Fig.  197. — Diagram  showing  Condition  of 
Cervix  at  End  of  Pregnancy  (MiiH-er^. 


THE  CERVIX  IX  THE  LATER  PART  OF  PREGNANCY 


209 


Fig.  198.- 


-Cervix  at  the  End  of  Pregnancy 
(Waldeyer).     X% 


canal  remains  praidjeally  unaltered  until  t])Q  rm*r|-  0f  labour,  -I'vl  that  it 
may  even  be  slightly  Longer  than  in  the  non-pregnant  condition,  thus  indi- 
cating   thai    the    cervix    shares 
somewhal  in  the  general  hyper- 
trophy of  the  uterus. 

In  recent  years  the  results 
obtained  by  examination  during 
life  have  received  additional 
conlirmat  ion  from  the  study  of 
frozen  sections  made  through 
the  bodies  of  women  dying  late 
in  pregnancy.  Valuable  contri- 
butions along  these  lines  have 
been  math'  by  Waldeyer,  Schroe- 
der.  Braune  and  Zweifel,  Pi- 
nard  and  Yarnier,  Leopold,  and 
others. 

Lower  Uterine  Segment. — 
For  a  short  time  after  the  ap- 
pearance of  Midler's  work  in 
1868,  the  question  concerning 
the  behaviour  of  the  cervix  was 
regarded  as  practically  settled; 
but  these  hopes  were  rudely 
shattered  in  1872  by  the  studies 
of  Braune  upon  frozen  sections 
made  through  a  woman  who  had 
died  during  the  second  stage  of 
labour.  His  specimen  showed 
distinctly  that  the  interior  of 
the  uterus  was  divided  into  two 
parts  by  a  projecting  circular 
ridge,  which  was  10  and  11  cen- 
timetres above  the  margins  of 
the  dilated  external  os,  its  situa- 
tion oeinginarTEeir"T)y  a  large 
vein  and  by  the  deflection  of  the 
peritonaeum  from  the  anterior 
surface  of  the  uterus  (Fig.  201). 
The  portion  above  it  possessed 
thick  walls,  while  the  remainder 
appeared  as  a  simple,  thin- 
walled,  muscular  tube  through 
which  the  head  ""had:'  partially 
passed.  Braune  identified  this 
ring  or  ridge  with  the  internal 

os,  and  concluded  that  everything  below  it  had  been  derived  from  the 
cervix;  nor  did  he  think  it  remarkable  that  the  small  canal  which  had  ex- 


Fig.  199. — Cervix  at  the  End  of  Pregnancy 
(Braune  and  Zweifel).     X  Vi- 


Fig.  200. — Cervix  at  the  End  of  Pregnancy,  show- 
ing Preservation  of  Canal  (Leopold).     X  %• 


210 


OBSTETRICS 


isted  up  to  the  time  of  labour  should  have  been  converted  into  a  structure 
of  such  dimensions. 

Bandl,  in  his  work  upon  rupture  of  the  uterus,  which  appeared  in 
1875,  pointed  out  that  when  such  an  accident  occurs,  the  point  of  rup- 
ture is  nearly  always  situated  below  Braune's  ring — namely,  in  the 
lower  uterine  segment.  The  next  year  he  took  up  the  subject  again,  and  con- 
sidered it  inconceivable  that  the  cervical  canal,  which  was  only  2.5  to  3.5 
centimetres  long  at  the  end  of  pregnancy,  could  be  converted  in  a  few  hours 
into  the  structure  described  by  Braune.  He  therefore  concluded  that,  if 
the  upper  boundary  of  the  latter  really  represented  the  internal  os,  certain 
preparatory  modifications  must  have  taken  place  during  the  latter  part  of 
pregnancy  in  order  to  make  such  a  remarkable  change  possible.  He  be- 
lieved that  the  tissue  forming  the  outer  portion  of  the  cervix  was  gradually 
shifted  during  the  last  few  weeks  of  pregnancy,  so  that  it  became  incor- 
porated with  the  musculature  of  the  lower  portion  of  the  body  of  the  uterus, 
while  the  cervical  mucous  membrane  retained  its  original  position.  Accord- 
ing to  his  view,  then,  the  true  internal  os  was  situated  not  at  the  upper  ter- 
mination of  the  cervical  mucosa,  but  much  higher,  and  at  a  level  corre- 
sponding to  that  of  Braune's  ring. 

Although  Bandl's  complicated  explanation  is  no  longer  accepted,  his 
name  will  always  have  a  place  in  the  literature  of  the  subject.    Nor  should 


Fig.  201. — Frozen  Section  through  "Woman  dying  during  Second  Stage  of  Labour,  showing 

Contraction  Eing  (Braune). 

the  fact  be  lost  sight  of  that  to  him  we  are  indebted  for  our  clinical  con- 
ception concerning  the  lower  uterine  segment,  inasmuch  as  he  was  the  first 
to  distinguish  clearly  between  the  function  of  the  upper  contractile  and 


THE    LOWER    [JTER1NE   SEGMENT 


211 


\ 


active,  and  the  lower  passive  segments  of  the  uterus,  as  well  as  the  relation 
which  they  bear  to  the  occurrence  of  rupture. 

The  discussion  started  by  Band!  lias  been  responsible  for  an  immense 
literature,  and  even  now  the  question  cannot  be  regarded  as  definitely  set- 
tled. Two  main  views  have  been  ad- 
vanced concerning  the  nature  and 
origin  of  the  lower  uterine  segment. 
According  t<>  the  first,  it  is  derived 
partly  from  the  cervix,  the  internal 
os  being  supposed  to  be  situated  3  or 
1  centimetres  above  the  external, 
while  the  rest  of  the  structure  is 
formed  by  the  lower  portion  of  the 
body  of  the  uterus.    According  to  the 

structure, 


Contraction 
rinse. 


Internal  os 


External  os. 


Internal  09. 


External  os. 


Fig.  202. — Diagram  illustrating  Main  Views 
as  to  Nature  of  Lower  Uterute  Seg- 
ment (American  Text-Book  I. 


sec-olid  view;,  the  entire 
from  Braune's  ring  to  the  external 
os,  is  derived  from  the  cervix.  The 
'first  view  has  received  the  indorse- 
ment of  such  authorities  as  Schroe- 
der,  Ruge,  von  Franque,  Dittel,  and 
Veit,  while  the  correctness  of  the 
second  explanation  is  upheld  by 
Bandl,  Kiistner,  Bayer,  Zweifel,  and 
others. 

At  first  glance  it  might  appear  strange  that  the  question  has  given  rise 
to  such  divergence  of  opinion,  as  it  would  seem  a  very  simple  matter  to 
demonstrate  the  structure  of  the  parts  by  microscopical  examination.  If 
the  first  view  be  correct,  the  inner  surface  of  the  portion  which  is  sup- 
posed to  be  derived  from  the  uterus  should  be  lined  by  decidua,  and  the 
portion  below  it,  corresponding  to  the  cervical  canal,  by  the  characteristic 
cervical  mucosa.  On  the  other  hand,  if  the  second  explanation  is  to  be 
accepted,  the  entire  structure  below  Braune's  ring — the  contraction  ring,  as 
it  is  generally  designated — should  be  lined  by  cervical  epithelium. 

Unfortunately,  the  question  is  not  so  easily  solved.  In  the  first  place, 
the  formation  of  the  contraction  ring  and  the  lower  uterine  segment  is  in 
great  part  a  clinical  phenomenon;  and  while  its  situation  can  usually  be 
definitely  made  out  by  the  examining  finger  during  labour,  it  is  not  so 
clearly  marked  after  the  removal  of  the  uterus  from  the  dead  body.  Again, 
the  majority  of  the  specimens  which  have  been  relied  upon  to  settle  the 
question  were  frozen  before  being  subjected  to  microscopical  examination, 
so  that  the  finer  histological  details  had  become  obliterated.  In  spite  of 
these  obstacles,  however,  the  question  has  gradually  approached  a  solution, 
so  that  the  majority  of  investigators  are  inclined  to  accept  the  first  view, 
which  is  generally  known  by  Schroeder's  name;  and  the  recent  mono- 
graphs of  von  Franque  and  Dittel  practically  settle  the  matter  beyond  all 
doubt.  To  these  the  reader  is  referred  for  the  full  literature  upon  the 
subject. 

Plate  IX  represents  a  vertical  mesial  section  through  the  uterus  of  a 


212 


OBSTETRICS 


woman  seven  months  pregnant,  who  died  at  the  Johns  Hopkins  Hospital 
during  premature  labour.  In  this  it  is  clearly  seen  that  the  external  os 
is  not  dilated,  hut  that  the  cervical  canal  has  become  obliterated  and  a 
distinct  lower  uterine  segment  has  been  formed.  Careful  examination 
shows  that  the  latter  is  lined  with  a  typical  cervical  mucous  membrane  for 
a  distance  of  3.5  to  4  centimetres  from  the  margins  of  the  external  os, 
whereas  above  this  point  the  tissue  is  distinctly  uterine  in  appearance  and 
is  covered  by  decidua. 

Fig.  203  represents  part  of  a  frozen  section  through  a  pregnant  cadaver, 
shown  in  Plate  I,  which  was  kindly  placed  at  my  disposal  by  Drs.  J.  Holmes 


Fig.  203. — Frozen  Section,  showing  Condition  of  the  Birth  Canal  in  First  Part  of  Second- 
Stage  of  Labour.     X  %• 
C.R.,  contraction  ring  ;  o.e.,  external  os. 

Smith  and  L.  E.  JSTeale.  The  woman,  who  had  a  slightly  generally  con- 
tracted rhachitic  pelvis,  died  in  labour  with  the  membranes  protruding 
from  the  vulva.  The  child  presented  by  the  breech,  which  had  not  yet 
become  engaged.  The  cervical  canal  was  obliterated  and  the  external  os 
fully  dilated,  its  margins  being  1  millimetre  thick.  There  was  no  trace 
of  the  internal  os.  Seven  centimetres  above  the  external  os  was  a  well- 
marked  contraction  ring.  Unfortunately,  the  specimen  was  so  badlv  macer- 
ated that  the  lining  membrane  of  the  cervical  canal  and  lower  uterine  seg- 
ment had  disappeared.  Microscopical  examination  revealed  only  a  few 
cervical  glands  in  the  neighbourhood  of  the  external  os,  and  gave  no  infor- 
mation as  to  whether  the  portion  below  the  contraction  ring  was  lined  by 
decidua  or  cervical  epithelium. 


PLATE   IX. 


SEVEN  AND   A  HALF   MONTHS'  PREGNANT    UTERES  FROM   WOMAN  DYING  IN 
THE  FIRST   STAGE   OF  LABOUR.      X  Va. 


THE    LOWEB    UTERINE   SEGMENT 


213 


Veil  has  lately  pointed  out  thai  the  portion  of  the  uterus  from  which 
the  lower  uterine  segmenl  is  to  develop  is  clearly  indicated  even  in  the  non- 
pregnant condition.  He  demonstrated  that  for  several  millimetres  above 
the  internal  os  the  Lower  part  of  the  uterine  cavity  is  represented  by  a  small 
canal,  which  he  designated  as  the  "Engpass"  (narrow 
passage),  and  from  which  he  believes  the  structure  in  ques- 
tion is  developed.  Fig.  128,  representing  a  six-  to  seven- 
weeks'  pregnant  uterus  in  my  possession,  clearly  shows  a 
similar  condil  ion. 

It  is  possible  that  the  cervix  may  occasionally  take  a 
larger  share  in  the  formation  of  the  lower  uterine  segment 
than  is  here  indicated,  but  what  we  have  said  undoubtedly 
holds  good  for  the  vast  majority  of  cases. 

Eofmeier,  in  1886,  demonstrated  that  the  structure  of 
the  lower  uterine  segment  is  not  homogeneous,  and  that 
the  portion  which  corresponds  to  the  cervix  is  composed 
of  dense  connective  tissue  rich  in  elastic  fibres,  -while  its 
upper  part  is  made  up  of  muscular  lamella?  which  pursue 
an  almost  parallel  course,  -whereas  as  soon  as  the  contrac- 
tion ring  is  reached  the  uterine  musculature  takes  on  its 
characteristic  appearance. 

Changes  in  the  Uterus  during  the  First  Stage  of  La- 
bour.— Passing  from  these  more  or  less  theoretical  consid- 
erations to  the  condition  of  the  uterus  at  the  onset  of 
labour,  we  find  that  the  organ  is  made  up  of  two  parts:  a 
large,  thin-walled,  muscular  sac — the  body — to  the  lower 
end  of  which  the  small  cervix  is  attached.  The  wall  of 
the  former  rarely  exceeds  5  millimetres  in  thickness.  It 
is  lined  by  decidua  and  the  foetal  membranes,  inside  of 
which  are  the  amniotic  fluid  and  the  foetus.  The  cervix  is 
softened  and  very  succulent.  It  presents  a  more  or  less 
fusiform  canal,  3  to  -A  centimetres  long,  which  is  bounded 
at  its  upper  and  lower  ends  by  the  internal  and  external  os 
respectively;  its  walls  rarely  exceed  1.5  centimetre  in 
thickness.  The  condition  of  the  external  os  varies  con- 
siderably, according  as  the  patient  is  a  primiparous  or  mul- 
tiparous  woman.  In  the  former  it  is  quite  tightly  closed 
and  barely  admits  the  tip  of  the  little  finger;  while  in 
the  latter  it  is  widely  gaping,  so  that  the  index  finger  can 
be  readily  passed  into  it,  and  can  frequently  be  carried 
up  to  the  internal  os. 

During  labour,  under  the  influence  of  the  uterine  con- 
tractions, the  uterus  becomes  differentiated  into  two  dis- 
tinct portions,  which  are  separated  from  one  another  by 
the  contraction  ring.    The  upper  is  the  active  contractile  portion  and  be- 
comes thicker  as  labour  advances,  while  the  lower  plays  a  merely  passive 
part,  becoming  converted  into  a  muscular  tube  for  the  transmission  of  the 
foetus  (Fig.  206). 


Fig.  204.  —  Sectiox 
through  Lover 
Utekixe  Segment 
axd  Cervix, show- 
ing Ehoitboidal 
Arraxgemext  of 
Muscle  Fibres  ix 
ForiieraxdDexse 
Structure  ix  Lat- 
ter iHofrneier). 

P.,  peritoneal  cover- 
ing of  uterus ;  o.e., 
os  externum  ;  o.i., 
os  internum. 


214 


OBSTETRICS 


With  the  onset  of  labour  pains  the  fluid  contents  of  the  uterus  are  sub- 
jected to  pressure.  As  the  lower  uterine  segment  and  the  cervix  will  natu- 
rally constitute  a  point  of  least  resistance,  the  fluid  pressure,  which  is  trans- 


Fig.  205 


20(1. 


Figs.  205,  206. — Diagrams  of  Birth  Canal  at  End  of   Pregnancy  and  during  Second  Stage 
of  Labour,  showing  Formation  of  Birth  Canal  (Sehroeder). 

mittecl  equally  in  all  directions  by  the  amniotic  fluid,  consequently  gives 
rise  to  an  increased  tension  and  distention  of  these  portions  of  the  uterus. 
On  abdominal  palpation,  before  the  rupture  of  the  membranes,  two  zones 
can  readily  be  differentiated,  the  upper  one  of  which  is  firm  and  hard  during 
a  contraction,  while  the  lower  affords  a  semifluctuant  sensation.     The  for- 


Fig.  207. — Dilatation  of  Cervix,  Funnel-shaped  Obliteration  of  Internal  Os  and 
Cervical  Canal  (Leopold). 


mer  represents  the  contractile  portion  of  the  uterus,  the  latter  the  passive 
lower  uterine  segment  and  cervix. 

Again,  since  the  cervix  is  perforated  by  its  canal,  the  fluid  pressure 
exerted  by  the  bag  of  waters  tends  to  cause  its  obliteration  and  final  dilata- 
tion, which  is  aided  by  the  traction  exerted  upon  its  margins  by  the  con- 


DILATATION   OF  THE   CERVIX 


215 


trading  fibres  of  the  lower  portion  of  the  uterus.  When  complete  dilata- 
tion lias  Ihh'h  cllVcted,  the  margins  of  the  external  os  lie  10  to  11  centi- 
metres below  the  contraction  ring,  and  no  trace  of  the  internal  os  can  be 


Fig.  208. — Dilatation  of  Cervix  fvrtiier  advanced  than  in  Fig.  207  (Leopold).     X  1. 

found.  At  the  same  time  the  bladder  is  gradually  drawn  up  in  front  of 
the  lower  uterine  segment  until  it  becomes  almost  entirely  an  abdominal 
organ. 

The  dilatation  of  the  cervix  may  be  regarded  as  consisting  of  two  stages: 
first,  obliteration  of  the  canal;  and  second,  dilatation  of  the  external  os. 
The  obliteration  occurs  from  above  downward,  the  beginning  being  indi- 
cated by  a  funnel-shaped  depression  at  the  region  of  the  internal  os,  which 
gradually  increases  in  extent  and  depth  until  the  entire  canal  has  disap- 
peared, when  the  uterine  cavity  is  separated  from  the  vagina  merely  by 


Fig.  209. — Cervical  Canal  completely  obliterated,  External  Os  Intact.     X  1. 


the  external  os.  This  is  clearly  shown  in  Figs.  207,  208,  and  209,  and 
also  in  Figs.  210,  211,  212,  and  213,  which  represent  reconstructions 
from  the  frozen  sections  of   Schroeder,   Winter,   Saxinger,   and   Tibone, 


216 


OBSTETRICS 


all  of  which  were  made  through  women  who  died  during  the  first  stage 
of  labour. 

After  the  cervical  canal  has  become  obliterated,  dilatation  of  the  ex- 
ternal os  occurs.     In  many  instances  its  margins  become  extremely  thin, 

and  occasionally  give  a  sen- 
sation as  if  they  would  cut 
the  examining  finger.  This 
change  is  brought  about  al- 
most entirely  by  the  force 
exerted  by  the  bag  of  waters, 
or  when  that  has  ruptured 
prematurely,  by  the  pressure 
of  the  presenting  part  itself. 
The  course  of  events  dif- 
fers considerably  according 
as  the  woman  is  in  her  first 
or  a  subsequent  pregnancy. 
In  the  former  case  marked 
resistance  is  offered  by  the 
external  os,  and  a  consider- 
able time  must  elapse  before  complete  dilatation  is  accomplished;  while 
in  the  latter,  the  os  is  gaping  and  very  little  force  is  required  for  its  com- 
plete dilatation  after  the  cervical  canal  has  become  obliterated. 

Changes  in  the  Uterus  during  the  Second  Stage  of  Labour. — During  the 
first  stage  of  labour  the  contractions  of  the  uterus  have  resulted  in  its 
differentiation  into  two  parts,  which  are  separated  from  one  another  by  the 


Fig.  210. — Dilatation  of  Cervix,  Funnel-shaped  Ob- 
literation of  Internal  Os  ;  Canal  2  Centimetres 
Long  (Schroecler).    X  %■ 


Fig.  211. — Dilatation  of  Cervix,  all  but  Low- 
er 10  Millimetres  of  Canal  obliterated  ; 
External  Os  Unchanged  (Winter).     X  }4- 


Fig.  212. — Dilatation  of  Cervix,  all  but 
Lower  3  Millimetres  of  Canal  obliter- 
ated ;  External  Os  Unchanged  (Saxin- 
ger).     XK- 


contraction  ring.  Above  is  the  active,  contractile  portion,  which  becomes 
thicker  as  labour  advances,  while  below  we  have  the  thin-walled,  passive, 
lower  uterine  segment  and  cervix  (Fig.  206). 


TIIK    FORCES   COXCKUNKI)    IN    LABOL'K 


217 


Fig.  213. — Dilatation  of  Cervix,  Canal  obliter- 
ated ;  External  Os  1.5  Centimetre  ix  Diam- 
eter.    Placenta  Pr.eyia.     (Tibonej.     X  %• 


While  these  changes  arc  being  effected,  there  has  been  no  advance  <>n 
the  pari  of  the  foetus,  and  as  a  rule  the  presenting  pari  occupies  the  same 
position  from  the  onsel  of  labour  until  complete  dilatation  of  the  cervix. 
With  the  commencemenl   of  the 
second    stage,    however,    descenl 
begins,  ami  under  normal  condi- 
tions continues  slowly  bul  stead- 
ily until  delivery  is  accomplished. 
Naturally,  the  differentiation  into 
stages  is  more  or  less  arbitrary, 
so   that    it   occasionally  happens 
thai   the  presenting  part  begins 
to  descend  during  the  latter  part 
(•f  t  he  first  staged 

After  it  has  brought  about 
complete  dilatation  of  the  cervix, 
the  bag  of  waters  has  subserved 
it-  function,  and  rupture  usually 
now  occurs,  which  is  manifested 
by  a  sudden  rush  of  a  greater  or 
l,esser  quantity  of  a  tolerably 
clear  fluid  from  the  vagina.  Oc- 
casionally the  membranes  give  way  some  time  before  complete  dilatation 
of  the  cervix  has  been  brought  about;  whereas,  on  the  other  hand,  in  rare 
instances  they  may  retain  their  integrity  until  the  completion  of  labour, 

so  that  the  foetus  is  born  surrounded  by  them, 
the  portion  covering  its  head  being  designated 
as  a  caul. 

We  have  already  directed  attention  to  the 
changes  in  shape  which  the  uterus  presents  dur- 
ing contraction.  These  may  be  noticed  in  the 
first,  but  more  especially  in  the  second  stage, 
when  the  organ  increases  considerably  in  length, 
and  at  the  same  time  diminishes  in  its  transverse 
and  antero-posterior  diameters  with  each  contrac- 
tion. The  increase  in  length  is  due  almost  entire- 
ly to  the  stretching  of  the  lower  uterine  segment: 
but  we  are  unable  to  make  definite  statements  as 
to  its  extent,  for  at  present  we  possess  no  means 
of  ascertaining  how  far  the  retraction  of  the  upper 
portion  of  the  uterus  may  serve  to  counterbalance 
the  stretching  of  its  lower  segment.  In  obstruct- 
ed labours,  in  which  marked  disproportion  exists 
between  the  size  of  the  presenting  part  and  the 
pelvic  canal,  the  lower  uterine  segment  is  sub- 
jected to  excessive  stretching,  and  consequently 
the  contraction  ring  assumes  a  much  higher  level,  and  not  infrequently  can 
be  palpated  as  a  distinct  transverse  ridge  a  short  distance  below  the  umbili- 


-  - 


Fig.  21-4. — Diagram  showing 
Action  of  Intra  -  lterine 
Pressure,   Membrane-   N'>t 

Rl'I'TlRED. 


218 


OBSTETRICS 


cus.  With  the  formation  of  the  lower  uterine  segment,  the  upper  portion  of 
the  uterus  increases  markedly  in  thickness,  and,  as  labour  proceeds,  covers 
a  progressively  decreasing  portion  of  the  child.  Thus,  when  the  head  is 
upon  the  perineum  less  than  one  half  of  the  foetus  is  in  the  upper  seg- 
ment. 

Forces  Concerned  in  Labour. — As  long  as  the  membranes  are  unruptured 
— that  is,  during  the  entire  first  stage  of  labour,  and  in  the  rare  instances 
in  which  they  remain  intact  in  the  second  stage — whatever  force  is  exerted 
by  the  contracting  uterus  is  transmitted  to  the  liquor  amnii,  and  by  it  to  the 
foetus.    In  accordance  with  the  laws  of  fluid  pressure,  therefore,  it  is  applied 

with  equal  intensity  to  all  portions  of  the  child, 
and  were  it  not  that  the  lower  uterine  segment 
and  cervix  represent  the  point  of  least  resistance 
in  the  uterus,  all  its  effect  would  be  wasted; 
whereas,  under  the  circumstances,  it  gives  rise  to 
the  formation  of  the  lower  uterine  segment  and 
the  dilatation  of  the  cervix,  but  plays  no  part  in 
causing  the  descent  of  the  child.  Attention  was 
first  directed  to  this  point  by  Schatz  and  Lahs, 
and  all  subsequent  authorities  have  accepted 
their  conclusions. 

After  rupture  of  the  membranes,  a  greater 
or  lesser  portion  of  the  amniotic  fluid  escapes, 
but  in  vertex  presentations  the  presenting  part 
usually  acts  as  a  fairly  efficient  tampon  and 
causes  the  retention  of  a  considerable  quantity 
of  it  in  the  uterus^  where  it  fills  out  the  inter- 
stices between  the  foetus  and  the  uterine  walls. 
Lahs  believed  the  amount  retained  was  usually 
sufficient  to  prevent  actual  contact  with  the  sur- 
face of  the  foetus,  and  that  therefore  extrusion  of 
the  latter  was  broirght  about  by  fluid  pressure  alone.  He  argued  that  under 
such  circumstances  (Fig.  215)  the  entire  surface  of  the  foetus,  except  the 
portion  projecting  through  the  cervix,  would  be  subjected  to  fluid  pres- 
sure, which,  as  it  is  equal  in  all  directions,  would  exert  no  effect  upon  the 
foetus,  except  in  a  line  passing  through  the  centre  of  the  portion  not 
subjected  to  it,  thus  manifesting  itself  as  a  downward  force  bringing  about 
descent. 

On  the  other  hand,  Lahs  held  that  in  all  other  presentations,  as  well  as 
in  those  of  the  vertex  when  the  amniotic  fluid  has  almost  completely  drained 
off,  other  factors  come  into  play  which  he  regarded  as  distinctly  patho- 
logical. In  such  cases  the  contracting  uterus  would  come  in  direct  con- 
tact with  the  surface  of  the  foetus,  and  the  force  exerted  by  the  fundus 
would  be  directly  transmitted  to  the  presenting  part  by  way  of  the  verte- 
bral column. 

Most  recent  writers  have  not  hesitated  to  accept  Lahs's  interpretation, 
but  Olshausen  has  lately  directed  attention  to  the  fact  that  the  latter 
force  comes  into  play  even  in  normal  vertex  presentations.     He  pointed 


Fig.  215.  —  Diagram  showing 
Action  of  Intra  -  uterine 
Pressure  after  Eupture  of 
the   Membranes. 


TIIK    FORCES  CONCERNED    IN    LABOUR 


2  It) 


Fig.  216. — Diagram  showing  Di- 
rect Pressure  exerted  by 
Fundus  after  Rupture  of  the 
Membranes. 


u;ii  thai  only  four  frozen  sections,  through  women  dying  in  the  second  stage 

of  labour,  are  available  for  the  study  of  the  question— namely,  two  of 

Braune  and  those  of  Chiari  and   Barbour— and  thai   in  three  of  them  the 

fundus  was  in  direct  contacl  with  the  breech 

of  the  cliilil.     Il«'  then  estimated  thai  at  Leasl 

300  cubic  centimetres  of  amniotic  fluid  were 

required    to   fill   ou1    the   interstices  between 

the  surface  of  the  foetus  and  the  uterine  wall, 

and   staled    thai    il    was  out    of   the  question 

thai    the  child   could    be   expelled   solely   by 

fluid  pressure  unless  a  greater  quantity  than 

this  were  present. 

In  200  eases  lie  measured  the  amount  of 
amniotic  fluid  escaping  when  the  child  was 
born,  which  practically  represents  the  quan- 
tity remaining  in  the  uterus  after  rupture  of 
the  membranes,  and  found  that  in  80  per  cent 
of  the  primiparse  it  did  not  exceed  300  cubic 
centimetres;  while  in  60  per  cent  it  was  not 
over  200  cubic  centimetres,  an  amount  by  no 
means  sufficient  to  fill  out  the  interstices,  let 
alone  to  firing-  about  the  separation  of  the 
breech  from  the  fundus,  which  is  absolutely 
essential  for  the  proper  action  of  fluid  pres- 
sure. He  therefore  concluded  that  under  such  circumstances  direct  pres- 
sure must  be  exerted  by  the  contracting  uterus  upon  the  breech,  whence 
it  is  transmitted  through  the  vertebral  column  to  the  head,  and  that 
this  is  rendered  possible  by  the  diminution  in  the  transverse  and  antero- 
posterior diameter  of  the  uterus,  which  results  in  an  extension  of  the 
child  and  its  conversion  for  the  time  being  into  a  comparatively  rigid 
object. 

In  addition  to  these  factors,  the  contractions  of  the  abdominal  muscles 
of  the  woman  also  play  no  mean  part  in  effecting  the  extrusion  of  the 
child;  indeed,  according  to  Schroeder,  they  alone  bring  it  about.  Ols- 
hausen,  on  the  other  hand,  while  not  denying  their  importance,  does  not 
consider  that  they  are  the  sole  factors  concerned.  It  is  apparent,  how- 
ever, in  most  cases,  that  their  action  is  absolutely  essential  for  the  birth 
of  the  foetus,  for  when  it  is  entirely  absent,  or  only  partially  comes 
into  play,  labour  is  delayed,  and  a  resort  to  forceps  frequently  becomes 
necessary. 

The  descent  of  the  child  is  no  doubt  partly  due  to  the  fact  that  it  be- 
comes straightened  out  by  the  action  of  the  pains  during  the  second 
stage.  According  to  Schroeder,  its  length  from  vertex  to  breech  is  in- 
creased by  5.5  centimetres  as  a  result  of  this  extension;  while  Olshausen 
considers  that  the  increase  is  considerably  greater,  and  estimates  that  it 
varies  from  7.25  to  13  centimetres  in  70  per  cent  of  the  cases.  Part  of 
this,  it  is  true,  is  counterbalanced  by  the  greater  length  of  the  uterus,  but 
the  remainder  is  accounted  for  by  the  descent  of  the  presenting  part. 
15 


220 


OBSTETRICS 


When  the  head  has  descended  through  the  pelvis  and  is  resting  on  the 
pelvic  floor,  more  than  half  of  the  entire  length  of  the  child  lies  beneath 
the  contraction  ring;  moreover,  as  the  upper  portion  of  the  uterus  becomes 
smaller  and  smaller,  it  necessarily  exerts  a  diminished  effect  upon  the 
child,  so  that  in  the  majority  of  cases  it  becomes  essential  that  the  ab- 
dominal contractions  should  participate  in  the  work.- 

Immediately  after  the  birth  of  the  child  a  marked  change  occurs  in 
the  position  and  size  of  the  uterus,  and  on  palpation  it  can  be  distin- 
guished as  a  firm,  rounded  body  which  reaches  to  the  umbilicus.  At  this 
time  its  contracted  and  retracted  body  is  freely  movable  above  the  col- 
lapsed lower  uterine  segment,  and  can  readily  be  displaced  in  any  desired 
direction. 

Changes  in  the  Vagina  and  Pelvic  Floor  during  Labour. — The  outlet 
of  the  pelvis  is  closed  by  a  number  of  layers  of  tissue,  which  together  consti- 
tute what  is  known  as  the  pelvic  floor.     Beginning  from  within  outward 


ve  (Kelly). 


one  meets  .successively  with  the  peritonaeum,  the  subperitoneal^  conn entjy p. 
tissue,  the  internal  pelvic  fascia,  the  levator  ani__and  jcoccygeus  muscles, 
the  external  pelvic  and  perineal"  fascia,  and,  included  between  the  latter, 
the  superficial  muscles  ofj^e  permieum,  external  to  which  are  the  sub- 


THE    FORCES   CONCERNED    IX    LABOUR 


221 


>  ut.inoous  tissue  and  the  cutaneous  covering  of  the  perineal  and    vulvar 
regions. 

( )f  these  structures  the  most  important  are  t  he  levator  aiiiinuscle_4nd  the 
fascia  covering  its  upper  and  lower  surfaces,  which  for  practical  obstetrical 
purposes  may  be  considered  as  constituting  the  pelvic  floor.     This  muscle 


Fig.  218. — The  Pelvic  Floor  peex  from  below  (Kelly). 

closes  the  lower  end  of  the  pelvic  cavity  as  a  diaphragm,  and  presents  a 
concave  upper  and  a  convex  lower  surface.  On  either  side  it  consists  of 
a  pubic  and  iliac  portion;  the  former  is  a  band  2  to  2.5  centimetres  in 
width,  which  arises  from  the  horizontal  ramus  of  the  pubis  3  to  -A  centi- 
metres below  its  upper  margin,  and  1  to  1.5  centimetre  from  the  s}Tmphysis 
pubis.  Itsr  fibres  pass  back-ward  and  encircle  the  rectum,  giving  off  a  few 
fibres  which  pass  behind  the  vagina.  The  greater  or  iliac  portion  of  the 
muscle  arises  on  either  side  from  the  white  line,  the  tendinous  arch  of  the 
pelvic  fascia,  and  from  the  ischial  spine,  at  a  distance  of  about  5  centi- 
metres below  the  margin  of  the  superior  strait.  Its  fibres  do  not  possess 
a  uniform  arrangement,  but,  according  to  the  researches  of  Dickinson,  the 
following  portions  can  be  distinguished:  Passing  from  before  backward, 
there  is  a  narrow  band  which  crosses  the  pubic  portion  and  descends  to  the 
recto-vaginal  septum.  The  greater  part  of  the  muscle  passes  backward  and 
unites  with  that  from  the  other  side  of  the  rectum,  while  the  posterior  por- 
tions meet  together  in  a  tendinous  rhaphe  in  front  of  the  coccyx,  the  most 
posterior  fibres  being  attached  to  the  bone  itself.  The  muscle  fails  to  fill 
out  the  posterior  and  lateral  portions  of  the  pelvic  floor,  which  are  occu- 
pied by  the  pyriformis  and  eoccygeus  muscles  on  either  side. 

The  levator  ani  muscle  varies  from  3  to  5  millimetres  in  thickness, 
though  its  margins,  which  encircle  the  rectum  and  vagina,  are  somewhat 
thicker.     On  contraction  it  serves  to  draw  both  the  rectum  and  vagina 


222 


OBSTETRICS 


forward  and  upward  in  the  direction  of  the  symphysis  pubis,  and  is  to  be 
regarded  as  the  reai~closer  of  the  vagina,  since  the  constrictor  cunni,  one 
of  the  superficial  muscles  of  the  perinseurm  is  too  delicate  in  structure  to 
have  more  than  an  accessory  function. 

The  muscles  forming  the  pelvic  floor  would  not  be  sufficiently  strong 
to  afford  support  to  the  pelvic  contents  were  they  not  re-enforced  by  the 
strong  pelvic  fascia.  The  internal  pelvic  fascia,  which  forms  the  upper 
covering  of  the  levator  ani,  is  attached  to  the  margin  of  the  superior  strait, 
where  it  is  joined  by  the  fascia  lining  the  iliac  fossse,  as  well  as  the  trans- 
verse fascia  of  the  abdominal  walls.  It  passes  down  over  the  pyriformis 
and  the  upper  half  of  the  obturator  internus  muscle,  and  is  firmly  attached 
to  the  periosteum  covering  the  lateral  wall  of  the  pelvis,  the  white  line  indi- 
cating its  point  of  deflexion  from  the  latter,  whence 
it  spreads  out  over  the  upper  surface  of  the  levator 
ani  and  coccygeus  muscles. 

The  inferior  fascial  covering  of  the  pelvic  dia- 
phragm is  divided  into  two  parts  by  a  line  drawn 
between  the  ischial  tuberosities.  Its  posterior  por- 
tion consists  of  a  single  layer  which,  taking  its 
origin  from  the  sacro-sciatic  ligament  and  the 
ischial  tuberosity,  passes  up  over  the  inner  sur- 
face of  the  ischial  bones  and  the  obturator  internus 
muscles  to  the  white  line, 
in  whose  formation  it  takes 
part.  From  this  tendinous 
structure  it  is  reflected  at  an 
acute  angle  over  upon  the 
inferior  surface  of  the  leva- 
tor ani,  the  space  included 
between  the  latter  and  the 
lateral  pelvic  wall  being  des- 
ignated as  the  ischio-rectal 
fossa.  The  anterior  portion, 
or  the  perineal  fascia  proper,  fills  out  the  space  between  the  line  joining 
the  ischial  tuberosities  and  the  pubic  arch.  It  is  made  up  of  three 
layers:  (1)  The  deep  perineal  fascia  which  covers  the  anterior  portion  of 
the  inferior  surface  of  the  levator  ani  muscle  and  is  continuous  with  the 
fascia  just  described;  (2)  the  middle  perineal  fascia  which  is  separated 
from  the  former  by  a  narrow  space  in  which  are  situated  the  pudic  vessels 
and  nerves;  (3)  the  superficial  perineal  fascia  which,  together  with  the 
layer  just  described,  form  a  compartment  in  which  lie  the  sujo£xfLei&L 
perineal  muscles,  the  rami  of  the  clitoris,  the  vaginal  bulbs,  and  the  vulvo- 
vaginal glands.' 

The  superficial  perineal  muscles  consist  of  the  constrictor  cunni,  the 
ischio-cavernosi,  and  the  transversus  perinei  muscles.  These  structures 
are  delicately  formed  and  possess  no  obstetrical  significance,  except  the 
last-named  muscles,  which  are  always  torn  through  in  perineal  lacerations, 
when  they  serve  in  great  part  to  bring  about  gaping  of  the  wound. 


Fig.  219.- 


"THREE  LAYERS  OF 
THE  PERINEAL  FASCIA 


-Diagram   showing   Arrangement  of    Pelvic 
and  Perineal  Fascia  (Tarnierl. 


THE   FORCES   CONCERNED   IN    LA HOUR 

Urethra      Clitoris 


223 


M.  Constrictor  cunn 
M.   Ischio-cavernosus 


M.  transversus  perinei 


Centrum  tendincum 


Levator  ani 


Sphincter  ani 

Fig.  220. — Pelvic  Floor  distended  by  Presenting  Part,  showing   Superficial  Muscles  of 

Perineum  (Bumm). 

From  a  practical  point  of  view,  Hart  has  divided  the  pelvic  floor  into  two 
segments — pubic  and  sacral — which  are  separated  from  one  another  by  the 
vagina.     Their  condition  remains  practically  unchanged  throughout  the 


Fig.  221. — Frozen  Section,  showing  Condition  of  Birth  Canal  in  Last  Month  of  Pregnane 

(Braune  and  Zweifel).     X  %• 


224 


OBSTETRICS 


entire  duration  of  pregnancy,  except  that  towards  the  end  they  become  more 
relaxed,  owing  to  the  greater  succulence  and  some  oedema  of  the  tissues, 
which  are  manifested  by  a  slight  increase  in  thickness  and  a  certain  amount 
of  drooping. 

In  the  first  stage  of  labour  the  bag  of  waters  takes  part  in  the  dilata- 
tion and  distention  of  the  upper  portion  of  the  vagina,  but  after  its  rup- 
ture the  changes  occurring  in  the  pelvic  floor  are  due  entirely  to  the 
pressure  exerted  by  the  presenting  part.  As  this  descends,  the  pubic  seg- 
ment becomes  slightly  drawn  up  and  forced  against  the  inferior  and  pos- 
terior portions  of  the  symphysis.     On  the  other  hand,  the  sacralsegment 


«£  ocs-rw,*' 


Fig.  222. — Frozen  Section,  shotting  Condition  of  the  Birth  Canal  m  First  Part  of  Second 
Stage  of  Labour  (Braune).    X  Yz. 


undergoes  marked  changes,  becoming  pushed  downward  and  forward,  and 
subjected  to  great  stretching,  eventually  being  converted  into  a  thm-walled, 
tubular  structure — the  perineal  gutter.  Fig.  220  gives  a  good  idea  of  the 
changes  occurring  in  the  pelvic  floor,  and  demonstrates  the  important  part 
played  by  the  levator  ani  and  the  altogether  insignificant  function  of  the 
superficial  perineal  muscles.  "When  the  head  distends  the  vulva,  its  open- 
ing looks  upward  and  forward,  and  the  course  of  the  birth  canal  along  the 
pelvic  floor  follows  the  curve  indicated  in  Figs.  203  and  222. 

"Webster  has  pointed  out  that  the  most  marked  change  consists  in  the 
stretching-  of  JJiefibres  of  the  levator  ani  muscle  and  the  thinning1  of  the 


central  portion  of  the  perimeum.  which  becomes  transformed  from  a  wedge- 
shaped  mass  of  tissue  5  centimetres  in  thickness  to  a  thin,  almost  trans- 


THE    FORCES  CONCERNED    IX    LABOUR  225 

parent  membranous  structure  2  to  4  millimetres  thick.     At  the  same  time 
it  is  pushed  down  aboul  2.5  centimetres  from  its  original  position. 

When  the  perinseum  is  distended  to  the  utmost,  the  anus  becomes 
markedly  dilated,  and  presents  an  opening  which  varies  from  2  to  2.5  cen- 
timetres in  diameter,  through  which  the  anterior  wall  of  the  rectum  is  seen 
to  bulge.  WestphaleD  has  recently  called  attention  to  the  fact  that  these 
changes  may  he  accompanied  by  slighl  lesions  in  continuity.  They  were 
noted  in  13  per  cent  of  the  100  cases  studied  by  this  author,  and  were  some- 
times sufficiently  marked  to  he  accompanied  by  slight  haemorrhage. 


LITERATURE 

Bandl.     Ueber  Ruptur  der  Gebarmutter.     Wien,  1875. 

Ueber  das  Verhalten  des  Uterus  mid  Cervix,  etc.     Stuttgart,  1876. 
HARBOUR.     Atlas  of  the  Anatomy  of  Labour  Exhibited  in  Frozen  Sections.     Third  edition, 

Edinburgh,  1896. 
Bayer.     Zur  physiol.  mid  path.  Morphologie  der  Gebarmutter,  in  Freund's  Gyn.  Klinik. 

Stuttgart,  1885. 
Uterus  mid  unteres  LTterinsegment.     Archiv  f.  Gyn.,  1897,  liv,  18-71. 
Braune.    Die  Lage  des  Uterus  und  Fotus  am  Ende  der  Sehwangerschaft.    Leipzig,  1872. 
Braune  und  Zweifel.     Gefrierdurchschnitte  durch  den  Korper  einer  Ilochschwangeren. 

Leipzig,  1890. 
Chiari.      Ueber   die   topographischen    Verhaltnisse    des    Genitales    einer    intrapartum 

verstorbenen  Primipara.     Wien,  1885. 
Dickinson.     Studies  of  the  Levator  Ani  Muscle.     Araer.  Jour.  Obstet.,  1889,  xxii,  897-917. 
Dittel.     Die  Dehnungszone  des  schwangeren  und  kreissenden  Uterus.     Leipzig,  1898. 
Duncan.     On  the  Length  of  the  Cervix  Uteri  in  Advanced  Pregnancy.     Researches  in 

Obstetrics,  Edinburgh,  1868,  243-273. 
von  Franque.     Cervix  und  unteres  Uterinsegment.     Stuttgart,  1897. 

Untersuchungen  und  Erorterungen  zur  Cervixfrage.  Wi'irzburg,  1899. 
Hart.  The  Structural  Anatomy  of  the  Pelvic  Floor.  Edinburgh,  1880. 
Hofmeier.     Das  untere   Uterinsegment   in  anat.  und  klin.  Beziehung,  in   Schroeder's 

Der  schwangere  und  kreissende  Uterus.     Bonn,  1886,  21-74. 
Holst.     Beitrage  zur  Geburtshtllfe  u.  Gynakologie,  Heft  I,  130-169,  1865. 
KCstner.     Das  untere  LTterinsegment  und  die  Deeidua  cervicalis.     Jena,  1882. 
Lahs.     Zur  Mechanik  der  Geburt.     Marburg,  1869;  Berlin.  1872. 

Die  Theorie  der  Geburt.     Bonn,  1877. 
Langhans  und  Muller.     Weiterer  anat.  Beitrag  zur  Frage  vom  Verhalten  der  Cervix 

wahrend  der  Schwangerschaft.     Archiv  f.  Gyn.,  1879,  xiv,  184-189. 
Leopold.     Uterus  und  Kind.     Leipzig,  1897. 

Lott.     Zur  Anatomie  u.  Physiologie  der  Cervix  uteri.     Erlangen,  1872. 
LcsK.     The  Science  and  Art  of  Midwifery,  82,  new  edition,  1895. 
Mauriceau.     Traite  des  maladies  des  femmes  grosses,  etc.     6me  ed.,  1721,  t.  i,  97. 
Muller.     Untersuchungen   fiber   die  Verktirzung   der  Vaginalportion,  etc.     Scanzoni's 

Beitrage,  1868,  v,  191-346. 
Olshausen.     Beitrag  zur  Lehre  vom  Mechanismus  der  Geburt.     Stuttgart,  1901. 
Pinard  et  Varnier.     Etudes  d'anatomie  obstetricale  normale  et  pathologique.     Paris, 

1892. 
Roederer.     Elementa  Artis  Obstetriciae.     Gottingae,  1766,  26. 
Ruge.    Ueber  die  Contraction  des  Uterus  in  anat.  u.  klin.  Beziehung.     Zeitschr.  f.  Geb. 

u.  Gyn.,  1880,  141-148. 
Saxinger.     Gefrierdurehschnitt  einer  Kreissenden.     Tubingen, 


226  OBSTETRICS 

Schatz.     Der  Geburtsmechanismus  der  Kopfendlagen.     Leipzig,  1868. 

Beitrage  zur  physiologischen  Geburtskunde,  1871. 
Schroeder.     Der  schwangere  und  kreissende  Uterus.     Bonn,  1886. 

Lehrbuch  der  Geburtshulfe,  XIII.  Aufl.,  l?3,  1899. 
Stoltz.     Considerations  sur  quelques  points  relatifs  a  l'art  des  accouchements.     These  de 

Strasbourg,  1826. 
Taylor.     On  the  Cervix  Uteri.     Amer.  Med.  Times,  June  21,  1862. 
Tiboxe.     Sulla  placenta  praevia  tavole  omolografiche  preparate  sopra  il  cadavere  conge- 

lato.     Turin,  1394. 
Varnier.     Le  col  et  le  segment  inferieur  a  la  fin  de  la  grossesse,  etc.     Paris,  1888. 
Veit.     Unteres  Uterinsegment  und  Cervixfrage.     VTerh.  der  deutschen  Gesell.  f.  Gyn., 

1899,  viii,  430-449. 
Waldeyer.     Medianschnitt  einer  Hochschwangeren  bei  Steisslage  des  Fotus.    Bonn,  1886. 
Webster.     The  Female  Pelvic  Floor.     Researches  in  Female  Pelvic  Anatomy,  93-112. 

Edinburgh,  1892. 
von  Westphalen.     Ueber  das  Verhalten  des  Mastdarms  withrend  der  Geburt.     D.  I., 

Strassburg,  1900. 
Winter.     Zwei  Medianschnitte  durch  Gebarende.     Berlin,  1889. 
Zweifel.     Zwei  neue  Gefrierschnitte  Gebarender.     Leipzig,  1893. 


C11APTEU  XII 


PHYSIOLOGY  OF  LABOUR  (Continued) 


MECHANISM    OF    LABOUR    IN    VERTEX    PRESENTATIONS 

Vertex  presentations  occur  in  from  96  to  97  per  cent  of  all  cases,  and 
in  them,  as  was  first  pointed  out  by  Naegele,  the  sagittal  suture  nearly  al- 
ways occupies  the  right  oblique  diameter  of  the  pelvis.  In  other  words, 
one  usually  has  to  deal  with  a  left  occipito-iliac  anterior,  or  a  right 
occipito-iliac  posterior  presentation.  That  this  is  so,  and  that  the  first- 
mentioned  presentation  is  the  one  most  frequently  observed,  practically 
all  the  authorities  are  agreed;  but  that  wide  differences  of  opinion  exist  as 
to  the  relative  frequency  of  the  several  other  varieties  is  clearly  shown  by 
the  following  table: 


Pinard  in  500  cases.       The  author  in  1,687  cases. 


L.  0.  I.  A  .  . 
L.  0.  I.  P  . . 
R.  0.  I.  A.  . 
R.  0.  I.  P.. 


52.6  per  cent. 
11      '     " 
.2       " 

38 '.8       " 


60.9  per  cent. 
2.6       " 
22.3       " 
14.2       " 


Mechanism  of  Left  and  Right  Occipito-iliac  Anterior  Presentations.— 
We  shall  consider  in  the  first  place  the  mechanism  of  labour  in  the  anterior 


Fig.  223. — Diagram  showing  Child 
ix  L.  0.  I.  A. 


Fig.  224. — Diagram  showing  Child 
in  E.  O.  I.  A. 


varieties  of  vertex  presentations — namely,  the  left  and  right  occipito- 
iliac  anterior. 

227 


228 


OBSTETRICS 


Diagnosis. — The  way  in  which  the  foetus  is  presenting  is  most  reliably 
determined  by  abdominal  palpation,  which  can  be  utilized  not  only  during 
pregnancy  but  also  at  the  time  of  labour,  provided  it  be  practised  in  the 
intervals  between  the  pains.     Its  accuracy,  however,  is  markedly  impaired 


Fig.  225. — Frozen  Section  through  Woman  at  End  of  Pregnancy,  Child  in  K.  0.  I.   T. 

(Zweifel). 

in  patients  with  very  fat  abdominal  walls,  or  in  whom  the  uterus  is  unduly 
distended  by  an  excessive  amount  of  amniotic  fluid,  or  deformed  by  sub- 
peritoneal or  intramural  myomata,  which  may  occasionally  be  mistaken 
for  portions  of  the  child. 

For  purposes  of  diagnosis  we  employ  the  manoeuvres  already  de- 
scribed, and  with  the  foetus  in  the  left  occipito-iliac  position  obtain  the 
following  data: 


First  manoeuvre : 
Second  manoeuvre : 

Third  manoeuvre: 


Fourth  manoeuvre : 


Irregular  breech  at  fundus. 

Resistant  plane  of  back  in  the  left  and  anterior  portion  of  the 
abdomen,  with  the  small  parts  on  the  right  side. 

If  the  head  be  not  engaged,  it  is  felt  as  a  freely  movable  body  over 
the  superior  strait ;  but  if  the  head  is  fixed,  the  anterior  shoulder 
may  be  detected. 

Negative  if  the  head  be  not  engaged ;  otherwise  the  cephalic  promi- 
nence is  felt  on  the  right  side  (Plate  X). 


For  the  right  occipito-iliac  anterior  position  we  obtain  the  following: 

First  manoeuvre:        Irregular  breech  at  fundus. 

Second  manoeuvre :     Resistant  plane  of  back  in  the  right  and  anterior  portion  of  the 

abdomen,  with  the  small  parts  on  the  left  side. 
Third  manoeuvre:        As  in  L.  0.  I.  A. 
Fourth  manoeuvre :     Cephalic  prominence  on  the  left  side. 


PLATE   X. 


First  manoeuvre. 


Second  manoeuvre. 


-— ~ 


J    O  C  JS  . 

Fourth  manoeuvre. 


Third  manoeuvre. 
PALPATION  IN  LEFT  OCCIPITO-ILIAC-ANTEEIOE  PRESENTATION. 


MECHANISM  OF  LABOUR  IN  OCCIPITOANTERIOR   PRESENTATIONS    229 

Until  tlic  lu';i< I  has  become  engaged  the  information  obtained  by  vagi- 
nal examination  is  extremely  meagre;  and  even  after  engagemenl  satis- 
factory results  cannot  be  obtained  until  the  cervis  is  sufficiently  dilated  to 
permit  the  finger  to  distinguish  the  various  sutures  and  dontanelles. 

In  the  Left  anterior  variety,  the  sagittal  suture  occupies  the  right 
oblique  diameter  of  the  pelvis,  with  the  small  Eontanelle  in  the  neighbour- 
hood of  the  left  ilio-pectineal  eminence  and  the  Large  Eontanelle  directed 
towards  the  right  sacro-iliac  synchondrosis.  In  the  right  anterior  variety, 
the  sagittal  suture  occupies  the  left  oblique  diameter,  the  small  fontanelle 
Lying  in  the  neighbourhood  of  the  right  ilio-pectineal  eminence,  while  the 
Large  fontanelle  looks  towards  the  left  iliac  synchondrosis. 

The  diagnostic  value  of  vaginal  examination  is  further  impaired  by  the 
fact  that  the  presence  of  a  marked  caput  succedaneum  may  make  it  im- 
possible to  feel  the  sutures  and  fontanelles,  not  to  speak  of  differentiating 
between  them. 

In  the  left  anterior  positions,  the  fatal  heart  sounds  are  usually  heard 
on  the  left  side  of  the  abdomen  along  a  line  joining  the  umbilicus  and  the 
left  anterior  superior  spine  of  the  ilium;  and  in  right  positions  at  a  corre- 
sponding point  on  the  right  side. 

Mechanism. — Owing  to  the  relatively  small  size  and  irregular  shape  of 
the  pelvic  canal  and.  the  large  dimensions  of  the  mature  foetal  head,  it  is 
apparent  that  any  portion  of  the  latter,  chosen  at  random,  cannot  neces- 
sarily pass  through  every  ]3lane  of  the  former;  hence  it  follows  that  some 
process  of  adaptation  or  accommodation  of  suitable  portions  of  the  head  to 
the  various  pelvic  planes  is  necessary  to  insure  the  completion  of  child- 
birth. This  is  brought  about  by  certain  movements  of  the  presenting 
part,  which  belong  to  what  is  termed  the  mechanism  of  labour. 

For  purposes  of  instruction,  we  are  obliged,  to  describe  the  various 
movements  as  if  they  occurred  separately  and  independently  of  one  another; 
whereas  in  reality  the  mechanism  of  labour  consists  of  a  combination  of 
movements,  several  of  which  are  going  on  at  the  same  time,  it  being  ex- 
tremely rare  for  any  individual  one  to  take  place  totally  irrespective  of  the 
others.  These  movements  are  divided  into  two  classes,  according  as  they 
are  absolutely  essential  to  the  completion  of  labour,  or  as  they  merelv 
facilitate  its  progress.  To  the  first  group  belong  the  cardinal  movements — 
descent,  internal  rotation,  and  extension;  to  the  second  the  accessory  move- 
ments— flexion  and  external  rotation. 

Engagement. — The  mechanism  by  which  the  presenting  part  enters  the 
superior  strait  is  designated  as  engagement.  This  is  best  studied  in  women 
who  have  borne  one  or  more  children,  for  the  following  reason:  In  primip- 
arse  the  head  descends  into  the  pelvic  canal  some  weeks  before  the  onset 
of  labour,  and  when  there  is  no  disproportion  between  the  two,  the  most 
dependent  portion  of  the  presenting  part  lies  just  above  a  line  joining  the 
ischial  spines;  whereas  in  muciparous  women  this  frequently  does  not 
occur  until  the  commencement  of  labour  pains. 

In  most  multiparas  at  the  end  of  pregnancy  the  head  is  freely  movable 
above  the  superior  strait,  or  rests  upon  one  or  other  iliac  fossa,  and  occu- 
pies a  position  midway  between  flexion  and  extension.    Accordingly,  when 


230 


OBSTETRICS 


the  uterus  begins  to  contract  and  to  force  it  towards  the  pelvic  opening, 
the  cephalic  circumference  which  first  reaches  it  is  the  one  that  passes 
through  the  extremities  of  the  fronto-occipital  diameter,  which  normally 
measures  11.5  centimetres.  Now,  as  the  conjugata  vera  is  only  11  centi- 
metres in  length,  it  is  apparent  that  a  normal-sized  head  cannot  engage 
with  its  sagittal  suture  directed  antero-posteriorly.  It  is  true  that  Sentex, 
Midler,  and  McKerron  have  recently  revived  the  old  teachings  as  to  the 
possibility  of  such  an  occurrence,  and  have  reported  cases  of  moderately 
contracted  pelves  in  which  the  head  engaged  in  this  manner,  with  the  small 
fontanelle  situated  either  just  behind  the  symphysis  pubis  or  just  in  front 
of  the  promontory  of  the  sacrum;  but  inasmuch  as  in  all  of  these  cases  the 
labour  proved  to  be  extremely  difficult,  it  is  evident  that  such  conditions 
must  be  considered  as  distinctly  pathological. 


Fig. 


22G. — Position  of  Fcetcs  before 
Engagement. 


Fig.  227. — Position  of  Fcetus  after 
Engagement. 


As  has  already  been  said,  the  head  usually  enters  the  superior  strait  in 
one  of  its  oblique  diameters  (12.75  centimetres),  usually  the  right,  with  one 
end  of  the  sagittal  suture  directed  towards  the  left  ilio-pectineal  eminence, 
and  the  other  towards  the  right  sacro-iliac  synchondrosis.  This  is  brought 
about  by  two  factors.  In  the  first  place,  the  foetus,  in  the  later  months  of 
pregnancy,  usually  assumes  this  position  spontaneously;  and  secondly,  the 
posterior  end  of  the  left  oblique  diameter  is  encroached  upon  by  the  rec- 
tum; so  that,  for  practical  purposes,  it  is  shorter  than  the  right. 

At  first  glance  it  may  appear  strange  that  the  head,  does  not  engage  in 
the  transverse  diameter  of  the  pelvis,  which  measures  13.5  centimetres; 


MECHANISM   OF   LABOUR    IN   OCCIPITOANTERIOR    PRESENTATIONS     231 

!Uit  u|„.|i  one  recalls  the  norma]  outlines  of  the  superior  strait  (Figs.  228 
and  229)  it  is  seen  thai  the  promontory  of  the  sacrum  juts  forward  in  such 
a  manner  as  to  make  it  impossible  for  engagemenl  to  occur  in  this  way,  as 
the  available  transverse  diameter  is  considerably  shorter  than  the  oblique. 


Fig.  228.  Fig.  229. 

Figs.  228,  229.— Diagrams    showing    why    the    Head    does   not   Engage   in  the   Transverse 

Diameter  of  the  Superior  Strait. 

The  mechanism  of  engagement  has  given  rise  to  a  great  deal  of  dis- 
cussion. Xaegcle  believed  that  it  took  place  in  such  a  way  that  the  sagittal 
suture  assumed  an  eccentric  position,  being  nearer  the  promontory  of  the 
sacrum  than  the  symphysis,  and  that  therefore  the  anterior  parietal  hone 
of  the  foetus  was  first  felt  on  vaginal  examination — Xaeaele's  obliquihi. 
Varnier,  on  the  other  band,  from  the  study  of  the  various  frozen  sections 
at  bis  disposal,  concluded  that  the  head  entered  the  pelvis  in  an  exactly 
opposite  direction — namely,  with  its  sagittal  suture  nearer  the  symphysis 
pubis,  so  that  the  posterior  parietal  bone  was  first  felt  on  examination. 

Neither  of  these  views  are  quite  correct  when  the  pelvis  is  normal  and 
the  uterus  not  pendulous.  The  first  presupposes  that  the  axis  of  the  uterus 
is  to  be  found  somewhat  in  front  of  that  of  the  superior  strait,  and  the 
second,  that  it  lies  posterior  to  it.  It  would  seem  that  Varnier  overlooked 
the  fact  that  the  cadavers,  upon  which  his  conclusions  were  based,  were 
frozen  in  the  horizontal  position,  with  the  flaccid  uterus  resting  upon  the 
vertebral  column;  and  while  his  observations  were  perfectly  correct  under 
the  circumstances,  they  do  not  apply  to  the  living  woman,  in  whom  the 
uterus  rises  with  each  contraction,  so  that  its  long  axis  corresponds  more 
or  less  closely  with  that  of  the  superior  strait.  Moreover,  careful  vaginal 
examination  reveals  the  fact  that  the  head  usually  engages  in  such  a  man- 
ner that  its  sagittal  suture  lies  either  in  the  middle  of  the  pelvis  or  ap- 
proaches the  promontory  of  the  sacrum,  but  only  slightly  and  not  by  any 
means  to  the  extent  that  Xaegele  had  supposed.  On  the  other  hand,  the 
condition  of  affairs  noted  by  Varnier  obtains  only  in  those  cases  in  which 
considerable  disproportion  exists  between  the  size  of  the  head  and  the 
pelvis. 

Descent. — The  first  requisite  for  the  birth  of  the  child  is  descent,  which 
occurs  continuously,  though  slowly,  throughout  labour,  from  the  time  the 
head  engages  until  its  expulsion  from  the  vagina.  With  it  are  associated  the 
various  movements  to  which  reference  has  already  been  made.  Descent  is 
brought  about  by  four  forces:  (1)  Infra-uterine  fluid  pressure;  (2)  direct 


232 


OBSTETRICS 


pressure  of  the  fundus  upon  the  breech;  (3)  contraction  of  the  abdominal 
muscles;  and  (4)  extension  and  straightening  of  the  child's  body. 

As  the  anterior  surface  of  the  sacrum  and  the  posterior  surface  of  the 
symphysis  measure  12  and  5  centimetres  respectively,  it  is  apparent  that 
if  all  parts  of  a  body  passing  through  the  pelvic  cavity  are  to  reach  the 
inferior  strait  at  the  same  time,  the  one  lying  posteriorly  must  descend  much 
more  rapidly  than  the  anterior  portion.  This  compensatory  difference  in  the 
rate  of  descent  of  the  portions  of  the  presenting  part  occupying  the  anterior 
and  posterior  segments  of  the  pelvis  is  known  as  sijnclytism,  and  is  clearly 
illustrated  in  Fig.  230. 

Flexion. — As  soon  as  the  descending  head  meets  with  resistance, 
whether  it  be  from  the  margins  of  the  superior  strait  or  the  cervix,  the 
walls  of  the  pelvis  or  the  pelvic  floor,  flexion  results.     By  this  is  meant 

that  the  head  rotates 
about  its  transverse  axis 
in  such  a  manner  as  to 
bring  the  chin  into  more 
intimate  contact  with  the 
thorax,  thereb}^  substi- 
tuting the  suboccipito- 
bregmatic  for  the  fronto- 
occipital  diameter. 

This  is  a  purely  me- 
chanical phenomenon, 
and  is  due  to  the  man- 
ner in  which  the  head  is 
articulated  with  the  ver- 
tebral column,  whereby 
the  former  becomes  con- 
verted into  a  two-armed 
lever,  the  short  arm  ex- 
tending from  the  occipi- 
tal condyles  to  the  oc- 
cipital protuberance,  and 
the  long  arm  from  the  same  point  to  the  chin  (Fig.  234).  It  is  therefore  ap- 
parent that  when  resistance  is  encountered  the  long  arm  of  the  lever,  fol- 
lowing the  ordinary  laws  of  mechanics,  must  ascend,  while  the  short  arm 
descends,  and  thus  flexion  is  brought  about. 

The  point  of  the  birth  canal  at  which  this  movement  occurs  varies 
greatly.  If  descent  begins  before  the  external  os  is  fully  dilated,  especially 
if  its  margins  are  resistant,  flexion  may  be  completed  before  the  head  has 
left  the  uterus.  In  generally  contracted  pelves,  flexion  takes  place  in  an 
exaggerated  manner  while  engagement  is  going  on;  but,  as  a  rule,  when 
there  is  no  disproportion  between  the  presenting  part  and  the  pelvic  canal, 
it  does  not  occur  until  the  resistance  of  the  pelvic  floor  is  encountered. 

Internal  Rotation. — By  this  we  understand  a  turning  of  the  head  about 
its  vertical  axis  in  such  a  manner  that  the  occiput  gradually  moves  from 
the  position  which  it  originally  occupied  towards  the  symphysis  pubis. 


Fig.  230. — Diagram  illustrating  Synclitism  (Ahlfeld). 


MECHANISM  OF  LABOUR   IN  OCCIPITO-ANTERIOR  PRESENTATIONS    233 


In  left  positions  the  motion  is  from  left  to  right,  and  in  the 
tion  in  right  positions  i  Figs.  335  and  236). 


P«^       .'j 


Fig.    231. — Frozen-    Section.    Second    Stage    or    Labottr.    Child   in   E.  0.  I.   A.,   Membranes 
Unbuptubed  (Braune).     Compare  with  Fitr.  ii". 

Internal  rotation  is  absolutely  essential  for  the  completion  of  labour, 
except  when  the  child  is  abnormally  small,  and  in  the  anterior  positions 


r 


Fig.  232.  Fig.  233. 

Figs.  232,  233. — Diagrams  showing  Effect  of  Flexion, 

Conversion  of  Occipito-fbontal  into   Suboccipito-        Fig.  234.— Diagbam  showing  Head 
bbegmatic  Diameteb.  Lever  i  American  Text-Book  . 

always  occurs  in  the  direction  indicated.     Indeed,  no  matter  what  the 
original  position  of  the  head  may  be.  the  occiput  usually  rotates  to  the 
16 


234 


OBSTETRICS 


front,  although  exceptionally,  in  occipito-posterior  presentations,  it  may- 
turn  towards  the  hollow  of  the  sacrum.     It  should  be  remembered  that 


Fig.  235. — Diagram  showing  Anterior 
Rotation  from  L.  0.  I.  A. 


Fig.  236. — Diagram  showing  Anterior 
Rotation  from  R.  0.  I.  A. 


internal  rotation  does  not  occur  by  itself,  but  is  always  associated  with  the 
descent  of  the  presenting  part. 

Various  theories  have  been  advanced  in  the  attempt  to  exjflain  the  man- 
ner in  which  internal  rotation  is  brought  about,  and  a  vast  literature  has 
accumulated  upon  the  subject.  The  general  belief  has  been  that  it  is 
rendered  necessary  by  the  shape  of  the  pelvic  canal,  it  having  been  formerly 
taught  that  the  superior  strait  represented  an  ellipse  whose  long  axis  lay 
transversely,  and  the  inferior  strait  one  whose  long  axis  was  anteropos- 
terior; so  that  for  the  head  to  descend  it  was  necessary  that  its  sagittal 
suture  be  directed  transversely  or  obliquely  to  pass  through  the  former, 
and  antero-posteriorly  to  pass  through  the  latter.  A  little  consideration, 
however,  will  show  that  this  is  not  the  case,  for  the  inferior  strait  presents 
an  almost  circular  opening,  its  transverse  diameter  being  11  and  its  an- 
teroposterior 9.5  centimetres,  when  the  coccyx  is  in  its  usual  position, 
and  11.5  centimetres  when  it  is  displaced  backward  during  labour.  Var- 
nier  is  therefore  justified  in  concluding  that  the  shape  of  the  pelvis  alone 
does  not  necessarily  explain  the  production  of  this  movement;  and,  more- 
over, when  we  recall  the  fact  that  the  diameter  of  the  head,  which  passes 
through  it  during  expulsion,  is  not  the  fronto-occipital,  as  is  usually  stated, 
but  the  suboccipito-frontal,  which  measures  10.5  centimetres  (Fig.  237),  it 
is  evident  that  unless  some  other  factor  rendered  it  necessary,  the  head  could 
be  born  without  internal  rotation. 

This  factor  is  to  be  found  in  the  structure  of  the  pelvic  floor,  and 
particularly  in  the  levator  ani  muscle.  The  latter  is  perforated  by  a  nar- 
row slit,  through  which  the  head  must  pass.  This  opening,  even  when 
markedly  distended,  still  retains  an  oval  outline,  its  transverse  diameter 
\  always  remaining  considerably  less  than  its  antero-posterior,  and  to  this 
shape  the  head  must  adapt  itself  in  order  to  be  born.  Furthermore,  the 
curved  walls  of  the  perineal  gutter  offer  a  concave  inclined  plane  over 
which  the  rounded  head  readily  glides  in  its  downward  course. 


MECHANISM   OF   LABOUR   IN  OCCIP1TO-ANTERIOR   PRESENTATIONS 


This  explanation,  although  satisfactoiy  when  the  occiput  is  originally 
situated  in  the  anterior  portion  of  the  pelvis,  would  not  necessarily  seem  to 
apply  with  equal  force  to  those  cases  in  which  it  occupies  a  posterior  posi- 
tion. Bui  tin-  following  accounl  of  thibois's  experiment  clearly  demon- 
strates thai  even  under  such  circumstances  the  pelvic  floor  exerts  a  predomi- 
uating  influence  in  the  production  of  this  movement.  "  In  a  woman  who 
had  died  a  short  time  previously  in  childbed,  the  uterus,  which  had  remained 
flaccid  and  of  large  size  was  opened  up  as  far  as  the  cervical  orifice  and 
held  by  assistants  in  a  suitable  position  above  the  superior  strait.  The 
foetus  of  the  woman  was  then  placed  in  the  soft  and  dilated  uterus  in  the 
right  occipito-posterior  position.  Several  pupil-midwives  pushing  the 
foetus  from  above  readily  caused  it  to  enter  the  cavity  of  the  pelvis. 
Much  greater  force  was  needed  to  make  the  head  travel  over  the  perinaeum 
and  clear  the  vulva,  and  it  was  not  without  astonishment  that  we  saw.  in 
three  successive  attempts,  that  when  the  head  had  traversed  the  external 
genital  organs,  the  occiput  had  turned  to  the  right  anterior  position,  while 
the  face  was  turned  to  the  left  and  to  the  rear.  In  a  word,  rotation  had 
taken  place  as  in  natural  labour.  We  repeated  the  experiment  a  fourth 
time,  but  as  the  head  cleared  the  vulva  the  occiput  remained  posterior. 
We  then  took  a  dead-born  foetus  of  the  previous  night,  but  of  much  larger 
size  than  the  preceding,  and  placed 
it  in  the  same  position  as  the  first, 
and  twice  in  succession  witnessed 
the  head  clear  the  vulva  after  hav- 
ing executed  the  movement  of  rota- 
tion. Upon  the  third  and  fol- 
lowing essays  delivery  was  accom- 
plished without  the  occurrence  of 
rotation.  Thus  the  movement  only 
ceased  after  the  perinaeurn  and  vul- 
va had  lost  the  resistance  which  had 
made  it  necessary,  or  at  least  had 
been  the  inciting  cause  of  its  ac- 
complishment." 

From  Solayres  de  Eenhac  (1771) 
to  the  present  time,  many  authors, 
among  whom  may  be  mentioned  Scanzoni,  Hodge,  and  Keynolds,  have 
sought  to  explain  the  production  of  rotation  by  calling  attention  to  the 
shape  of  the  pelvic  canal,  and  pointing  out  that  the  inclination  of  its  walls 
— the  inclined  planes  of_J]i£-pgltU*- — served  to  direct  the  occiput  anteriorly. 
By  others  it  was  thought  that  the  projecting  ischial  spines  also  played  a 
similar  part  by  interposing  an  obstacle  to  posterior  rotation. 

Schroeder  believed  that  the  movement  was  inaugurated  by  the  body  of 
the  child  rotating  in  such  a  way  as  to  bring  its  back  more  to  the  front,  and 
that  the  head  followed  it.  He  considered  that  this  was  brought  about  by 
an  attempt  on  the  part  of  the  uterus  to  assume  its  normal  flattened  shape, 
as  its  contents  were  expelled.  He  did  not  believe  that  the  shoulders  were 
rotated  until  the  bisacromial  diameter  was  directlv  transverse,  but  consid- 


1 


Fig. 


—Diagram  showing  Scboccipito-bkeg- 
mati'l.  sttboccipito  -  frontal,  and  occipito- 
FRONTAL Diameter*. 


236 


OBSTETRICS 


ered  that  they  remained  somewhat  behind  the  occiput — 30  degrees  accord- 
ing to  Schatz — and  that  the  movement  of  the  body  merely  inaugurated 
that  of  the  head,  which  was  still  further  accentuated  by  accessory  causes. 


Fig.  238. — Frozen  Section  through  Woman  in  Labour  with  Child  partly  delivered,  show- 
ing that  External  Eotation  of  the  Head  is  not  Dependent  upon  Eotation  of  the 
Shoulders  (Zweifel). 

Olshausen  has  recently  argued  in  favour  of  this  theory,  but  does  not 
seem  to  have  adduced  any  additional  evidence  in  its  support.  On  the  other 
hand,  the  recent  frozen  section  of  Zweifel,  through  a  woman  who  had  died 
just  after  the  birth  of  the  child's  head,  shows  that  the  latter  had  under- 


Fig.  239. — Diagram  showing  Delivery  of  Head  in  Vertex  Presentation. 


gone  a  complete  rotation,  while  the  shoulders  had  hardly  rotated  at  all, 
and  to  my  mind  offers  convincing  evidence  against  the  views  of  Schroeder 
and  Olshausen. 


MECHANISM  OF  LABOUR   IX  OCCIPITO-ANTERIOK   PRESENTATIONS    237 

Extension. — When,  after  internal  rotation,  the  sharply  Hexed  head 
reaches  the  vulva,  ii  undergoes  another  movemenl  which  is  absolutely  essen- 
tial to  its  birth — namely,  it  becomes  extended  so  thai  the  base  of  the  occipul 
comes  in  direct  contact  with  the  inferior  margin  of  the  symphysis  pubis. 
This  movement  is  brought  about  by  two  factors.  In  the  first  place,  as  the 
vulval  out  lei  looks  upward  and  forward,  extension  must  occur  before  the 
head  can  pass  through  it.  For  if  the  sharply  flexed  head,  on  reaching  the 
pelvic  floor,  continued  to  be  driven  downward  in  the  same  direct  ion  as  here- 
tofore— in  the  axis  of  the  superior  strait — it  would  impinge  upon  the  end 
of  the  coccyx  and  the  posterior  portion  of  the  perinaeum,  and  if  the  vis  a 
tergo  were  sufficiently  strong,  would  eventually  be  forced  through  the  peri- 
neal tissues.  But  when  the  head  presses  upon  this  structure,  two  forces 
come  into  play,  the  first  acting  downward,  exerted  by  the  uterus,  and  the  / 
second  upward,  supplied  by  the  resistant  pelvic  floor,  the  resultant  force  «^ 


Fig.  240. — Diagram  showing  Delivery  of  Head  in  Vertex  Presentation. 


being  one  directed  forward  and  somewhat  upward  in  the  direction  of  the 
vulval  opening,  thereby  giving  rise  to  extension. 

After  the  suboccipital  region  has  come  in  contact  with  the  inferior 
margin  of  the  symphysis  pubis,  the  head  is  no  longer  to  be  regarded  as  a 
two-armed,  but  simply  as  a  one-armed  lever,  the  occiput  being  the  ful- 
crum with  the  arm  extending  from  it  to  the  chin,  so  that  any  force  exerted 
upon  the  head  must  necessarily  lead  to  farther  extension.  As  this  becomes 
marked,  the  vulval  opening  gradually  dilates  and  the  scalp  of  the  child 
soon  becomes  apparent  through  it.  Now,  if  we  mark  the  point  which  first 
appears,  and  carefully  examine  the  child  after  its  birth,  we  find  in  left 
occipitoanterior  presentations  that  it  was  the  upper  and  posterior  margin 
of  the  right  parietal  bone  that  first  came  into  view,  while  the  reverse  holds 
good  in  right  occipito-anterior  positions. 

"With  increasing  distention  of  the  perinaeum  and  vaginal  opening,  a 
larger  and  larger  portion  of  the  occiput  gradually  appears,  and  the  head 


238 


OBSTETRICS 


is  born  b}-  further  extension,  the  occijDut,  bregma,  forehead,  nose,  mouth, 
and  finally  the  chin,  successively  passing  over  the  anterior  margin  of  the 
perinagum.  Immediately  after  its  birth  the  head  falls  downward  and  the 
chin  comes  in  contact  with  the  region  of  the  anus. 


Fig-.  241. — Diagram  showing  Delivery  of  Head  in  Vertex  Presentation. 


External  Rotation. — A  few  moments  after  its  birth  the  head  undergoes 
another  movement,  and,  when  the  occiput  has  been  originally  directed  to- 
wards the  left,  it  rotates  towards  the  left  tuber  ischii,  and  in  the  opposite 
direction  when  it  has  been  originally  towards  the  right.  This  is  known  as 
external  rotation  or  restitution,  and  is  simply  the  index  of  a  corresponding 
rotation  of  the  body  of  the  child,  which  serves  to  bring  its  bisacromial 
diameter  into  relation  with  the  antero-posterior  diameter  of  the  pelvic  out- 
let. This  movement  is  brought  about  by  essentially  the  same  factors  which 
produce  the  internal  rotation  of  the  head. 

Expulsion. — Almost  immediately  after  the  occurrence  of  external  rota- 
tion, the  anterior  shoulder  appears  under  the  symphysis  pubis,  and  in  a 
short  time  the  anterior  portion  of  the  perinaeum  becomes  distended  by  the 
posterior  shoulder,  which  is  first  born,  being  rapidly  followed  by  the  other. 
Finally,  the  body  of  the  child  is  quickly  extruded  along  a  curved  line  cor- 
responding to  the  axis  of  the  lower  part  of  the  birth  canal — that  is,  with 
its  upper  side  markedly  concave  and  its  lower  convex. 

Mechanism  of  Right  and  Left  Occipito-iliac  Posterior  Presentations. — 
In  1,687  cases  of  labour  at  the  Johns  Hopkins  Hospital  we  observed  283 
occipito-posterior  presentations  (16.8  per  cent),  the  occiput  being  directed 
to  the  right  in  239  cases,  and  to  the  left  in  11  cases,  a  proportion  of  about 
1  to  5.  From  our  figures  it  would  appear  that  these  presentations  occur  less 
frequently  than  is  usually  stated,  a  result  probably  due  to  the  fact  that 
many  of  our  patients  were  not  examined  until  well  advanced  in  labour; 
so  that  in  not  a  few  the  occiput,  which  was  originally  directed  posteriorly, 
had  undergone  anterior  rotation. 


PLATE   XL 


First  manoeuvre. 


Second  manoeuvre. 


Third  manoeuvre.  Fourth  manoeuvre. 

PALPATION  IN  EIGHT   OCCIPITO-ILIAC-POSTEBIOE  PKESENTATION. 


MECHANISM  OF'LABOUR  IN  OCCIPITO-POSTERIOIl  PRESENTATIONS   239 


Diagnosis. —  Palpation  in  a  right  occipito-iliac  posterior  presentation 
gives  the  following  data: 

First  manoeuvre:        The  fundus  is  occupied  by  the  breech. 

Second  manoeuvre:     The  resistant  plane  of  the  back  is  fell  well  back  in  the  right  Hank, 

the  small   parts  being  on  the  left  side  and  much  more  readily 

palpable  than  in  anterior  presentations. 
Third  manoeuvre :        Negative  if  the  head  is  engaged;  otherwise  the  movable  head  is 

detected  above  the  superior  strait. 
Fourth  manoeuvre:     Cephalic  prominence  on  the  left  side  (Plate  XI). 

Whenever  the  back  of  the  child  is  felt  on  the  right  side  of  the  mother, 
the  possibility  of  a  right  posterior  position  should  always  be  borne  in  mind, 
as  it  occurs  nearly  or  quite  as  frequently  as  the  right  anterior  variety.  It 
should  also  be  remembered,  whenever  the  small  parts  are  distinctly  felt 
in  the  anterior  portion  of  the  abdomen,  that  one  has  in  all  probability  to 
deal  with  a  posterior  position,  more  especially  in  the  rare  instances  in 
which  the  occiput  occupies  the  hollow  of  the  sacrum.  In  the  less  frequent 
left  posterior  positions,  palpation  gives  similar  results,  except  that  the 
back  is  felt  in  the  left  flank  and  the  small  parts  and  cephalic  prominence 
are  found  on  the  right  side  of  the  abdomen. 

On  vaginal  touch  in  the  right  posterior  position,  the  sagittal  suture 
occupies  the  right  oblique  diameter,  the  small  fontanelle  is  felt  opposite 
the  right  sacro-iliac  synchondrosis,  the  large  fontanelle  being  directed  to- 
wards the  left  ilio-pectineal  eminence,  while  in  the  left  position  the  re- 
verse obtains.  In  many  cases,  in  the  early  part  of  labour,  owing  to  imper- 
fect flexion  of  the  head,  the  large  fontanelle  lies  at  a  lower  level  than  in 
anterior  positions,  and  is  more  readily  felt. 


Fig.  242. — Diagram  showing  Child  in 
L.  0.  I.  P. 


Fig.  243. — Diagram  showing  Child  in 
K.  0.  I.  P. 


On  auscultation  the  heart  is  heard  in  the  right  or  left  flank  of  the 
mother,  according  as  one  has  to  deal  with  a  right  or  left  position.  But  it 
should  be  remembered  that  in  the  right  posterior  position  the  heart  sounds 
are  occasionally  transmitted  through  the  thorax  of  the  child,  and  are  best 
heard  either  in  the  middle  line  or  slightly  to  the  left  of  it.    This  is  due  to  a 


240 


OBSTETRICS 


partial  extension  of  the  head  and  the  altered  relation  of  the  body  of  the 
child,  whereby  the  thorax  comes  in  contact  with  the  anterior  uterine  wall. 


Fig.  244. — Diagram  shotting  Anterior  Rota- 
tion from  L.  0.  I.  P. 


Fig.  245. — Diagram  showing  Anterior  Rota- 
tion" from  E.  0.  I.  P. 


Mechanism. — In  the  vast  majority  of  occipito-posterior  presentations 
the  mechanism  of  labour  is  identical  with  that  observed  in  the  anterior 
varieties,  except  that  the  occiput  has  to  rotate  from  the  region  of  the  sacro- 
iliac synchondrosis  to  the  symphysis  pubis,  instead  of  from  the  llio-pec- 
tineal  eminence — through  135  degrees  instead  of  45  degrees. 

Not  infrequently  internal  rotation  does  not  take  place  until  the  peri- 
neum begins  to  bulge,  and  occasionally  does  not  occur  at  all,  spontaneous 
labour  being  then  out  of  the  question  unless  the  child  is  very  small.  This 
movement  usually  requires  considerable  time  for  its  completion,  so  that 
there  results  a  not  inconsiderable  prolongation  of  labour.  Yarnier  has 
compared  the  duration  of  labour  in  400  cases  of  occiput  posterior  with 


Fig.  246. — Diagram  showing  Posterior  Rota- 
tion from  L.  0.  I.  P. 


Fig.  247. — Diagram  showing  Posterior  Rota- 
tion from  E.  0.  I.  P. 


that  of  660  cases  of  occiput  anterior  presentation,  and  found  that  it  aver- 
aged three  hours  and  sixteen  minutes  to  one  hour  and  fifty  minutes  longer, 
according  as  the  patient  was  a  primiparous  or  multiparous  woman. 


MECHANISM  OF  LABOUR  IN  OCCIPI TO-POSTERIOR  PRESENTATIONS  241 

In  a  small  percentage  of  cases  the  occiput,  instead  of  rotating  anteri- 
orly, turn-  towards  the  sacrum,  so  that  ii  eventually  occupies  its  concavity. 
According  to  Wesl  this  occurs  in  3  per  cent  of  the  cases,  while  Varnier 
and  the  writer  have  noted  it  in  2  per  cent  and  8.1!.)  per  cent  respectively. 
In  many  instances  it  is  difficult  to  explain  why  posterior  rotation  occurs; 
but  when  the  head  is  imperfectly  flexed,  the  large  fontanelle  occupies  a! 
lower  level  than  the  small,  whence  it  would  appear  that  the  portion  of  the] 
head  which  remains  lowesl  is  the  one  which  rotates  anteriorly. 

After  the  occiput  has  rotated  into  the  hollow  of  the  sacrum,  the  child 
may  he  horn  in  one  of  two  ways.  Ordinarily  the  head  becomes  markedly 
Hexed  and  lengthened  in  its  mento-occipital  diameter  and  eventually  the 
region  just  anterior  to  the  large  fontanelle  impinges  upon  the  lower  mar- 
gin of  the  symphysis  pubis,  after  which  the  occiput  is  slowly  pushed  over 
the  anterior  margin  of  the  perinaeum.    Then  by  a  movement  of  extension 


Fig.  248. — Usual  Mechanism  of  Delivery  of  Head  wim  Occiput  m  Hollow  of  Sacrum. 

the  occiput  falls  backward,  and  the  brow,  nose,  mouth,  and  chin  appear 
successively  under  the  symphysis.  After  the  birth  of  the  head,  external 
rotation  and  expulsion  of  the  body  occur  in  the  usual  manner. 

According  to  Sentex,  "Winckel.  Weiss,  and  Muller,  the  head  is  occa- 
sionally born  by  another  mechanism,  which  comes  into  play  in  those  cases 
in  which  partial  extension  persists.  Under  such  circumstances  the  brow 
appears  at  the  vulva,  and  while  the  root  of  the  nose  impinges  upon  the 
symphysis,  by  a  movement  of  flexion  the  brow,  bregma,  and  occiput  suc- 
cessively pass  over  the  perinaeum,  until  finally  the  face  slips  out  from  under 
the  symphysis  pubis.  This  mechanism  approaches  closely  to  that  observed 
in  brow  presentations,  and  is  much  more  difficult  than  the  one  just  con- 
sidered, and  is  more  liable  to  lead  to  tears  of  the  maternal  soft  parts,  since 
it  is  evident  that  in  the  first  instance  the  vulva  is  distended  by  the  sub- 
occipito-frontal  diameter  of  the  head,  and  in  the  second  by  the  occipito- 
frontal, which  measure  respectively  10.5  and  11.75  centimetres. 


212 


OBSTETRICS 


Prognosis. — It  is  generally  believed  that  occipito-posterior  offer  a  much 
more  gloomy  prognosis  than  occipito-anterior  presentations.  This  is  proba- 
bly due  to  the  fact  that  Mauriceau,  Smellie,  and  all  the  early  authorities 
taught  that  in  such  cases  the  occiput  always  rotated  into  the  hollow  of  the 
sacrum.  It  is  true  that  Naegele  showed  that  posterior  rotation  was  only 
of  exceptional  occurrence,  and  that  in  the  vast  majority  of  cases  the  occiput 
rotated  anteriorly.  But  in  spite  of  his  teachings,  the  older  views  still  pre- 
vailed. Thus  Capuron,  in  1833,  taught  that  spontaneous  delivery  could 
not  take  place;  and  Tarnier,  while  admitting  the  correctness  of  Naegele's 
conclusions,  nevertheless  taught  that  the  prognosis  was  always  serious,  for 
even  when  anterior  rotation  occurred,  the  duration  of  labour  was  markedly 
increased  and  the  maternal  and  foetal  mortality  augmented. 

A  comparatively  large  experience  with  this  class  of  cases  has  led  me 
to  discount  somewhat  these  gloomy  views,  and  to  regard  the  occurrence 


.  Fig.  249. — Usual  Mechanism  of  Delivery  of  Head  with  Occiput  in  Hollow  of  Sacrum. 

of  posterior  presentations  with  equanimity.  Moreover,  in  view  of  our 
uniformly  good  results,  I  do  not  consider  it  advisable  to  attempt  to  con- 
vert them  into  other  positions  during  the  course  of  labour,  except  when  the 
forceps  is  to  be  applied.  It  is  true  that  labour  is  somewhat  prolonged  in 
these  cases,  and  instrumental  interference  is  required  more  frequently — 
in  10  per  cent  of  the  cases,  according  to  Varnier,  as  compared  with  3.6  per 
cent  in  anterior  presentations.  In  281  cases  in  which  delivery  occurred 
spontaneously  or  was  aided  by  forceps,  we  had  no  maternal  mortality  di- 
rectly attributable  to  the  posterior  position,  and  only  one  child  was  lost. 
Even  when  the  occiput  rotates  into  the  hollow  of  the  sacrum,  the  prog- 
nosis is  not  so  very  bad,  as  in  the  majority  of  cases  spontaneous  delivery 
occurs,  being  noted  by  Varnier  in  30  out  of  35  cases.  No  doubt  when  the 
occiput  remains  posterior  there  is  an  increased  tendency  towards  perineal 
tears,  which  is  particularly  marked  when  the  head  is  born  by  the  less  fre- 
quent mechanism.    But  to  my  mind  the  main  cause  of  the  dread  in  which 


CHANGES    IX   THE  SHAPE   <>!•     Ill 


HEAD 


243 


Fit 


posterior  presentations  are  held  is  the  fan  thai  they  frequently  escape  rec- 
ognition, and  accordingly,  when  for  any  reason  operative  delivery  becomes 

necessary,  i he  forceps  is  applied 
improperly — thai  is,  as  in  occipi- 
to-anterior  presentations. 

When  occipito-posterior  pres- 
entations have  descended  into 
the  pelvis,  it   is  my  practice  to 

i  leave  them  to  Nature  as  long  as 
possible,    and    to    interfere    only 

When  absolutely  necessary.  But 
when  convinced  that  the  best  in- 
terests of  tlie  mother  and  child 
will  he  subserved  by  prompt  de- 
livery, forceps  should  he  applied 
according  to  the  directions  which 
will  he  given  in  the  appropriate 
chapter.  On  the  other  hand, 
when  the  head  is  aurested  at  the 
superior  strait  in  a  posterior  posi- 
tion, version  should  be  resorted 
to  as  soon  as  one  is  convinced 
that  spontaneous  advance  will 
not    occur,   provided,    of   course, 

i  that  the  operation  is  feasible  and 

\  is  not  contra-indicated  by  dispro- 
portion between  the  size  of  the 
head  and  the  pelvis. 

Changes  in  the  Shape  of  the 
Head. — In  vertex  presentations 
the  child's  head  undergoes 
important  and  characteristic 
changes  in  shape,  as  the  result 
of  the  pressure  to  which  it  is 
subjected  during  labour.  In  pro- 
longed labours  in  which  the 
membranes  have  ruptured  before 
complete  dilatation  of  the  cervix. 
the  portion  of  the  head  immedi- 
ately over  the  os  is  relieved  from 
the  general  pressure  existing  in 
the  uterus,  and  as  a  consequence 
a  serous  exudate  occurs  under 
the  scalp  at  this  point,  giving 
rise  to  a  soft  swelling  which  is 
known  as  the  caput  succedaneum._  In  most  ca.ses  this  attains  a  thickness 
of  only  a  few  millimetres,  but  in  prolonged  labours,  under  the  circumstances 
named,  it  may  become  very  considerable  and  effectually  prevent  the  exam- 


251. 


Fig.  252. 
Figs.  250-252. — Disappearance  of  Caput  Succeda- 
neum;   Same  Head    at  Birth.  Three  and  Ten 
Days  respectively  after  Labour. 


244 


OBSTETRICS 


ining  finger  from  distinguishing  the  various  sutures  and  fontanelles.  More 
usually  the  caput  is  formed  when  the  head  is  in  the  lower  portion  of  the 
birth  canal,  and  not  infrequently  only  after  the  resistance  of  a  rigid  vaginal 
outlet  is  encountered.  It  occurs  upon  the  most  dependent  portion  of  the 
head/ and  therefore  in  left  occipito-iliac  positions  is  found  over  the  upper 
and  posterior  extremity  of  the  right  parietal  bone,  and  in  right  positions 
over  the  corresponding  area  of  the  left  parietal  bone.  Hence  it  follows  that 
in  many  instances  after  labour  we  are  enabled  to  diagnose  the  original  pres- 
entation by  the  situation  of  the  caput  succeclaneum. 

More  important,  however,  are'  tne  plastic  -changes  which  the  head  un- 
dergoes. Owing  to  the  fact  that  the  various  bones  of  the  skull  are  not 
firmly  united,  movement  may  occur  at  the  various  sutures.  Ordinarily  the 
margins  of  the  occipital  bone,  and  more  rarely  those  of  the  frontal  bone, 
are  pushed  under  those  of  the  parietal  bones;  and  in  many  cases  one  pa- 
rietal bone  may  overlap  the  other,  the 
rule  being  that  the  one  occupying  the 
posterior  position  is  overlapped  by  the 
anterior.  These  changes  are  of  marked 
significance,  especially  in  contracted 
pelves,  when  the  ability  of  the  child's 
head  to  become  moulded  may  make  the 
difference  between  a  spontaneous  labour 
and  a  major  obstetrical  operation. 

As  a  result  of  pressure  the  head  also 
undergoes  a  marked  change  in  shape, 
which  consists  in  a  diminution  of  its- 
suboccipito-mental  and  occipitofrontal 
diameters.  In  other  words,  it  becomes 
lengthened  from  chin  to  occiput  and  compressed  in  other  directions.  This 
is  clearly  shown  in  Fig.  253. 

In  occipito-posterior  presentations,  when  the  occiput  has  rotated  into 
the  hollow  of  the  sacrum,  the  frontal  bone  is  markedly  overlapped  by  the 
anterior  margins  of  the  parietal  bones,  which  leads  to  a  distinct  depres- 
sion of  that  part  of  the  head,  and  gives  some  idea  of  the  force  with  which 
the  region  of  the  large  fontanelle  has  been  pressed  against  the  lower  mar- 
gin of  the  symphysis. 


Fig.  253. — Diagram  showing  Configura 
tion  of  Head  in  Vertex  Presenta 
tion  (American  Text-Book). 


LITERATURE 

Capuron.    Memoire  sur  l'impossibilite  de  l'accouchement  naturel  et  la  necessite  du  forceps 
dans  les  positions  occipito-posterieures.    Bulletin  de  l'Acad.  de  Medecine,  Nov.  2, 1833. 

Dubois.     Quoted  by  Pinard. 

Quoted  by  Lusk.     The  Science  and  Art  of  Midwifery.     New  edition,  1895,  175. 

Hodge.     The  Principles  and  Practice  of  Obstetrics.     Philadelphia,  1866,  159-160. 

Mauriceau.     Traite  des  maladies  des  femmes  grosses,  etc.,  6me  ed.,  Paris,  1721. 

McKerron.    Antero-posterior  Position  of  the  Head  as  a  Cause  of  Difficult  Labour.     Trans. 
London  Obst.  Soc,  1900,  xli,  142-150. 

MtJXLER,  A.     Ueber  Hinterhauptslagen  und  Scheitellagen.     Monatsschr.  f.  G-eb.  u.  Gyn.,, 
1898,  vii,  382-399  and  534-550. 

Naegele.     Die  Lehre  vorn  Mechanismus  der  Geburt.     Mainz,  1838. 


MECHANISM    OF    LABOUR    IX   VERTEX    PRESENTATIONS  --'4:. 

Olshausex.     Beitrag  zur  Lehre  vom  Mechanismus  der  Geburt.     Stuttgart,  1901. 
Pinard.     Traiu'  du  palper  abdominal,  2me  <5d.,  Paris,  1889,  27  and  •'!;    1 1. 
Reynolds.     Mechanism  of  Labour.    Amer.  Text-Book  of  Obstetrics,  iv'.»;.  384-492. 
Scanzoni.     Lehrbuch  der  Geburtshiilfe,  II.  Anil..  Wien,  ls.i;;.  21'.). 
S(  hroedj  u.     Lehrbuch  der  Geburtshiilfe,  XIII.  And.,  1899,  187-188. 
Sentex.     Etude  statistique  et  clinique  sur  Irs  positions  occipito-posterieures.    Paris,  lsT'.'. 
Smellie.     A  Treatise  on  the  Theory  and  Practice  of  Midwifery.     Eighth  edition,  L774. 
Solayres  hi.  Renhac.     Dissertatio  de  partu  viribus  maternis  absolute     Paris,  1771. 
Tarnier.     De  I'accouchemenl  dans  les  occipito-posterienivs.     Seinaine  ined.,  Paris,  1889. 
Varnier.     De  I'attitude  de  la  tete  an  detroit  superieur  et  du  mechanisme  de  sou  eng   _ 
ment.     Annales  d'Obst.  et  de  Gyn.,  1897,  xlviii,  440-444. 

Accommodation  de  la  tete  foetale  an  bassin  maternel.     Obstetrique  journaliere,  Paris, 
1900,  131-149. 

Les  occipito-posterieures.     Obstetrique  journaliere,  1900.  181-1*4. 
Wi:iss.    Zur  Behandlung  der  Yorderseheitellagen.   Volkmann's  Sammlung  klin.  Vbrtrage, 

X.  P.     Nr.  60,  1892. 
West.     Cranial  Presentations,  etc.     Glasgow,  1857. 
Winckel.     Lehrbuch  der  Geburtshiilfe,  II.  Aufl.,  1893.  147-150. 
Zweiiel.     Zwei  neue  Gefrierschnitte  Gebarender.     Leipzig.  1893. 


CHAPTER  XIII 


PHYSIOLOGY  OF  LABOUR   (Continued) 

MECHANISM    OF    LABOUR    IN     FACE,    BROW,    AND 
BREECH    PRESENTATIONS 

Face  Presentations. — In  mento-iliac  presentations  the  head  is  markedly 
extended,  so  that  the  occiput  is  in  contact  with  the  hack,  while  the  face 
looks  downward.  Pinard,  in  an  analysis  of  92,026  cases  of  labour,  found 
374  face  presentations,  a  percentage  of  0.4  per  cent — that  is,  1  in  every 
250  cases. 

The  face  most  frequently  occupies  the  right  oblique  diameter  of  the 
pelvis,  so  that  the  chin  is  directed  either  towards  the  left  ilio-pectineal 


Fig.  254- 


-Diagp.au  showing  Position  of 
Child  in  L.  M.  I.  A. 


Fig.  255. — Diageaii  showing  Position  of 
Child  in  E.  M.  I.  A. 


eminence  or  the  right  sacro-iliac  synchondrosis.  Accordingly,  the  left 
mento-iliac  anterior  and  right  mento-iliac  posterior  are  the  varieties  usu- 
ally observed. 

It  is  generally  stated  that  face  presentations  do  not  exist  during  preg- 
nancy, but  owe  their  origin  to  extension  of  the  head  at  the  superior  strait 
at  the  onset  of  labour,  although  Mme.  La  Chapelle,  ISTaegele,  Spiegelberg, 
Ribemont-Dessaignes,  Fieux,  and  others  have  described  instances  in  which 
they  were  diagnosed  during  pregnancy.  These  are  designated  as  primary, 
246 


PLATE   XII. 


First  manoeuvre. 


Second  manoeuvre. 


Third  manoeuvre. 


Fourth  manoeuvre. 
PALPATION  IN  EIGHT  MENTO-ILIAC-ANTEEIOE  PEESENTATION. 


MECHANISM   OF    LABOUR    IX   FACE    PRESENTATIONS 


247 


in  contradistinction  to  the  much  more  frequent  secondary  face  presenta- 
tions. 

Diagnosis. —  In  the  left  mento-iliac  anterior  variety,  palpation  gives  the 
following  data: 

First  manoeuvre:        Breech  in  Fundus. 

Second  manoeuvre :  Back  in  the  right  and  posterior  portion  of  the  abdomen,  and  dis- 
tinctly felt  only  in  its  upper  portion;  small  parts  in  left  and 
anterior  port  ion  of  the  abdomen. 

Third  manoeuvre:       Marked  cephalic  prominence  on  right  side. 

Fourth  manoeuvre  :  Marked  cephalic  prominence  on  right  side  ;  fingers  can  be  depressed 
deeply  on  left  (Plate  XII). 

The  reverse  holds  good  in  the  right  posterior  variety.  The  character- 
istic sign  is  that  the  cephalic  prominence  can  be  palpated  on  the  same  side 
as  the  back,  the  latter  being  distinctly  felt  only  in  the  neighbourhood  of 
the  breech. 

On  vaginal  touch  the  face  is  found  in  the  birth  canal,  and  the  variety  of 
presentation  is  diagnosed  by  the  differentiation  of  the  various  features, 
the  mouth  and  nose,  malar  bones  and  orbital  ridges  being  the  distinctive 
points!  In  the  left  anterior  variety;  the  i_hin  occupies  the  anterior  and 
the  brow  the  posterior  extremity  of  the  right 
oblique  diameter  of  the  pelvis,  while  in  right 
posterior  positions  the  reverse  obtains. 

On  auscultation  the  heart  sounds  are  heard 
below  the  umbilicus  on  the  side  of  the  abdomen 
over  which  the  small  parts  are  felt;  in  other 
words,  they  are  trajismitted  through  the  tho- 
rax^ The  only  other  condition  in  which  this 
servation  obtains  is  in  .brow  presentations, 
and  in  the  rare  cases  of  occipito-posterior  pres- 
entations in  which  the  head  is  partially  ex- 
tended. 

Causation. — The  causes  of  face  presenta- 
tions are  manifold,  and,  roughly  speaking,  are 
afforded  by  any  factor  tending  to  bring  about 
'-xtension  or  to  prevent  flexion  of  the  head. 
Tli us,  marked  enlargement  of  the  neck  or 
thorax.  cqiIs  of  cord  about  the"neck,~or  spast i e 
'■"litraction  of  fhe"~ cervical  muscles,  may  act 
in  this  way.  Again,  it  is  well  known  that 
hemicephalic  children  usually  present  by  the 
face,  as  the  result  of  the  faulty  development 
of  the  cranial  vault. 

Hecker  pointed  out  that  face  presentations 
were  occasionally  due  to  an  elongation  of  the 
occipital  portion  of  the  head — dolichocephalus.  There  is  no  doubt  that 
most  children  that  are  born  by  the  face  have  heads  of  this  character,  but 
the  fact  that  they  usually  resume  their  normal  shape  a  few  days  after 


Tumour  of  Neck  caus- 


Fig.  256 

i>'<>  Face  Presextaticx. 


248 


OBSTETRICS 


-/ 


Fig.  251? 


_  _': — ?«3 
-Dolichocephalic  Head  from  Beeech 
Presentation  (Jelliughaus). 


labour  shows  beyond  question  that  the  deformity  is  the  result  rather  than 
the  cause  of  the  presentation.     Zweifel  delivered  by  Cesarean  section  a 

dolichocephalic   child,  which  had 
presented   by    the   breech    before 
operation,  and  considered  that  this 
case  demonstrated  the  possibility 
of  the  existence  of  a  primary  doli- 
V^B^  ■*      chocephalus;  but  Fritsch  and  most 
observers  contend  that  the  pecu- 
liar  shape   of   the  head  resulted 
from  pressure  exerted  upon  it'  by 
the  fundus  of  the  uterus.    On  the 
other  hand,  Jellinghaus  and  Gess- 
ner  have  recently  reported  cases 
which  they  believe  support  the  original  theory  of  Hecker;  and,  on  the  whole, 
it  would  seem  probable  that  such  a  condition  may  occasionally  bear  a  causal 
relation  to  face  presentations. 

Any  factor  which  interferes  with  engagement  of  the  head  favours  the 

1  /  production  of  face  presentations,  and  accordingly  we  find  that  they  occur 

more  frequently  when  the  pelvis  is  contracted  or  the  child  very  large.     It 

is  therefore  an  excellent  practical  rule  to  bear  this  latter  possibility  in 

mind  whenever  one  meets  with  lack  of  engagement  in  a  normal  pelvis. 

Matthews  Duncan  di- 
rected  attention   to   the 
I    most   frequent   cause   of 
face    presentations — 
namely,  an  oblique  posi- 


Fig.  258.  —  Diagram  showing 
that  in  Face  Presentations 
the  Occiput  is  the  Long 
End  of  Head  Lever. 


Fig.  259. — Diagram  illustrating  Impossibility  of  Labour 
in  Face  Presentations  when  the  Chin  is  directly 
Posterior. 


tion  of  the  uterus,  which  perrnjigjhe  child's  back  to  sag  towards  the  side 
to  which  the  vertex  lies.     He  pointed  out  that  under  such  circumstances 


MECHANISM    OF    LAIJUL'R   IN    PACE   PRESENTATIONS 


249 


the  altitude  of  the  foetus  becomes  distorted  and  abnormal,  so  that  a  slight 
obstacle  to  the  de>eent  of  the  posterior  portion  of  the  head  will  result  in  its 


Fig.  260. — Distention  of  Vulva  in  Face  Presentation  (modified  from  Ahlfeld). 

extension.     This  occurs  most  frequently  in  right  occipito-iliac  posterior 
presentations,  as  is  shown  by  the  fact  that  while  left  occipito-anterior  are 


Fig.  261. — Diagram  showing  Delivery  or  Head  en  FArE  Presentation. 

four  times  more  frequent  than  right  occipito-posterior  presentations,  the 
same  two  varieties  of  face  presentation  occur  with  almost  equal  frequency. 


250 


OBSTETRICS 


That  nmltiparity  would  naturally  favour  the  production  of  this  condition 
is  evident,  since  lax  abdominal  walls  allow  the  uterus  to  assume  an  oblique 
position.  Thus  Pinard  and  Winckel  state  that  60  per  cent  of  their  cases 
occurred  in  muciparous,  and  only  40  per  cent  in  primiparous  women. 


J.  OC/fi'/OJff. 


Fig.  262. — Diagram  showing  Delivery  of  Head  in  Face  Presentation. 

Mechanism. — As  face  are  usually  derived  from  vertex  presentations,  it 
is  apparent  that  the  farmer  are  but  rarely  observed  in  a  fully  developed 
state  at  the  superior  strait,  where  the  brow  generally  engages,  while  the 
face  descends  only  after  further  extension. 


Fig.  263. — Diagram  showing  Delivery  of  Head  in  Face  Presentation. 

The  mechanism  in  these  cases  consists  of  the  cardinal  movements — de- 
scent, internal  rotation  and  flexion;  and  the  accessory  movements — extension 
and  external  rotation.    Descent  is  brought  about  by  the  same  factors  as  in 


Mini  AX  ISM   OF   LABOUR    IX    PACE   PRESENTATIONS 


251 


vertex  presentations,  while  rxlcnsion  results  from  the  relation  which  the 
body  of  the  child  bears  to  its  head,  the  latter  being  converted  us  it  were 
into  a  two-armed  Lever,  the  Longer  arm  of  which  extends  from  the  occipital 
condyles  to  the  occiput;  so  that  when  resistance  is  encountered  the  latter  i> 
pushed  upward,  while  the  chin  descends  (Fig.  258). 

Internal  rotation  has  for  its  object  the  rotation  of  the  face  in  such  a 
manner  as  to  bring  the  chin  under  the  symphysis  pubis,  since  otherwise 
natural  delivery  cannot  be  accomplished.  Only  in  this  way  can  the  neck 
subtend  the  posterior  surface  of  the  symphy- 
sis pubis;  whereas,  if  the  chin  be  directed 
posteriorly,  the  short  neck  must  subtend 
the  anterior  surface  of  the  sacrum,  which 
measures  12  centimetres  in  length,  when  the 
birth  of  the  head  is  manifestly  impossible 
unless  the  shoulders  can  enter  the  pelvis  at 
the  same  time,  which  is  possible  only  with  \_/ 


-._^v ; 


Fig.  264. — Showing  Distortion  of 
Face  after  Delivery  in  Face 
Presentation. 


very  small  or  premature  children  (Fig.  259). 
After  anterior  rotation  the  chin  and 
mouth  appear  at  the  vulva;  the  under  sur- 
face of  the  chin  becomes  stemmed  against 
the  symphysis,  and  the  head  is  delivered  by 
a  movement  of  flexion,  the  nose,  eyes,  brow, 
bregma,  and  occiput  appearing  in  succession 
over  the  anterior  margin  of  the  perinseum 
(Figs.  261,  262,  and  263).  After  the  birth 
of  the  head  the  occiput  sags  backward  to- 
wards the  anus,  and  in  a  few  moments  external  rotation  occurs,  the  shoulders 
being  born  as  in  vertex  presentations. 

In  a  small  number  of  cases  internal  rotation,   instead   of   occurring 
anteriorly,  may  take  place  towards  the  hollow  of  the  sacrum.    Under  such 

circumstances,  for  the  reasons  given 
above,  the  birth  of  a  normal-sized  child 
is  impossible. 

In  mento-iliac  presentations  the  face 
becomes  distorted  owing  to  the  effusion 
of  serum  beneath  the  skin,  which  when 
marked  completely  obliterates  the  fea- 
tures and  is  very  likely  to  cause  con- 
fusion with  a  breech  presentation.     At 
the  same  time  the  skull  undergoes  con- 
siderable moulding,  which  is  manifested 
by  an  increase  in  length  of  the  mento- 
occipital  diameter  and  a  diminution  in 
the  vertical  diameters  of  the  head. 
Prognosis. — Until  the  latter  part  of  the  eighteenth  century  face  pres- 
entations were  considered  extremely  unfavourable,  and  most  authorities 
advised  their  conversion  into  some  other  variety.     But  about  that  time 
Deleurye,  in  France,  and  Zeller  and  Boer,  in  Austria,  pointed  out  that 


Fig.  265. — Diagram  showing  Configura- 
tion of  Head  in  Face  Presentation 
(American  Text-Book). 


252 


OBSTETRICS 


most  of  them  would  end  spontaneously  if  left  alone,  the  latter  author 
stating  that  he  had  observed  spontaneous  labour  in  T9  out  of  80  cases, 
and  had  applied  forceps  in  only  a  single  instance. 

Owing  to  the  excessive  distention  of  the  vulval  outlet  by  the  greatest 
circumference  of  the  head — the  mento-occipital — deep  tears  of  the  peri- 
nseum  are  of  frequent  occurrence;  and  owing  to  the  prolongation  of  labour 
the  foetal  mortality  is  markedly  increased,  being  usually  estimated  at  about 
14  per  cent,  though  Weiss  lost  only  1  out  of  78  children  (5.1  per  cent). 

In  dealing  with  face  presentations  it  should  always  be  borne  in  mind 
that  internal  rotation  does  not  occur  until  the  pelvic  floor  is  well  distended 
by  the  advancing  face;  and  frequently,  when  the  chin  is  obliquely  posterior, 
it  does  not  take  place  until  the  obstetrician  has  almost  abandoned  hope  of 
its  occurrence.  Nor  should  it  be  forgotten  that  the  face  must  occupy  a 
lower  level  than  the  vertex  before  one  can  feel  assured  that  the  greatest 
circumference  of  the  head  has  passed  through  the  superior  strait.  This 
can  be  readily  appreciated  from  a  study  of  Figs.  266  and  267,  in  which  it 
is  seen  that  the  distance  from  the  parietal  boss  to  the  vertex  is  only  3  centi- 
metres, whereas  a  line  drawn  from  the  same  point  to  the  face  will  measure 
7  centimetres. 

Treatment. — In  the  anterior  varieties  spontaneous  delivery  is  the  rule, 
and  even  when  the  chin  is  obliquely  posterior,  anterior  rotation  usually 
occurs,  although  often  not  until  a  very  late  period.  In  view  of  the  serious 
prognosis  attending  its  failure,  and  j)articularly  when  the  face  rotates  into 
the  hollow  of  the  sacrum,  in  appropriate  cases  an  attempt  should  be  made 


Fig.  266. — Diagram  showing  that  when  the 
Vertex  is  on  the  Line  joining  the  Ischial 
Spines,  the  greatest  Diameter  of  the 
Head  has  passed  the  Superior  Strait. 


Fig.  267. — Diagram  showing  that  when  the 
Face  is  on  the  Level  of  the  Ischial 
Spines,  the  Greatest  Diameter  of  the 
Head  is  still  Above  the  Superior  Strait. 


to  substitute  a  vertexprese-n  tntion .  "When  the  face  is  not  deeply  engaged 
this  can  be  readily  accomplished,  either  by  pushing  up  the  chin  or  by 
making  traction  upon  the  occiput. 

When  the  chin  is  directed  anteriorly,  attempts  at  conversion  are  not  ad- 
visable, as  they  would  merely  substitute  an  occipito-posterior  position, 
which  is  but  slightly  more  favourable  than  the  original  face  presentation, 
not  to  speak  of  the  increased  danger  of  sepsis  to  which  the  woman  must 


MECHANISM   OF    LABOUR    IX    PACE    PRESENTATIONS 


253 


necessarily   be  subjected  during  the   manoeuvre.     In  obliquely  posterior 
positions,  on  the  other  hand,  conversion  is  urgently  indicated,  and  should 

be  attempted  as  - i  as  the  condition   i-  recognised  and  the  degree  of 

of 


dilatation  of  the  cervix  permits.  I  ncier 
these  circumstances  the  unfavourable  men- 
to-posterior  is  converted  into  a  favourable 
occipito-anterior  presentation. 

From  time  to  time  numerous  methods 
have  hern  suggested  for  this  purpose,  the 
oldest  and  most  effectual  being  the  follow- 
ing, advocated  by  Baudeloeque  and  revived 
by  Thorn,  Weiss,  and  others:  Attempts  are 
made  to  push  up  the  chin  by  two  fingers_^ 
introduced  into  the  vagina;  if  this  does  not 
succeed  the  patient  is  anaesthetized,  the 
whole  hand  introduced,  and  the  head  dis- 
lodged, after  which  the  vertex  is  grasped 
and  drawn  down.  At  the  same  time  the  ex- 
ternal hand  o"t>the  operator  or  the  assistant 
carries  the  back  in  the  opposite  direction^ 
so  as  to  facilitate  flexion.  Very  excellent 
results  have  been  obtained  by  this  manoeu- 
vre, and  its  adoption  in  suitable  cases  can- 
not be  too  strongly  recommended. 

Sehatz  suggested  the  method  of  external 
manipulation  pictured  in  most  text-books, 
by  which  the  vertex  is  substituted  for  a  presenting  face.  This,  however,  is 
rarely  available,  inasmuch  as  the  presentation  does  not  become  well  devel- 
oped until  after  engagement  has  occurred. 

If  the  face  be  too  deeply  engaged  in  the  pelvis  to  admit  of  the  Baude- 
loeque manoeuvre,  the  patient  should  be  let  alone  and  descent  allowed  to 
take  place,  in  the  hope  that  external  rotation  will  occur  when  the  face 
reaches  the  pelvic  floor.  If,  however,  this  does  not  take  place  after  a  reason- 
able delay,  forceps  should  be  applied  in  the  manner  to  be  described  later, 
and  an  attempt-made  to  rotate  the  chin  to  an  anterior  position;  finally,  if 
this  fails,  the  only  resource  lies  in  craniotomy:  although  symphyseotomy 
has  been  suggested  by  Davis  in  such  cases. 

"When  the  chin  is  situated  directly  posteriorly,  and  attempts  at  con- 
version  have  failed,  podalic  version  should  be  performed  as  soon  as  the 
condition  of  the  crervi^w41F^5ermit ;  but  if  the  face  be  so  firmly  engaged 
that  it  cannot  be  pushed  up  under  anaesthesia,  craniotomy  or  symphyse- 
otomy must  be  resorted  to  as  soon  as  the  patienTs  condition  callsfor 
delivery.  The  former  has  been  repeatedly  practised,  but  so  far  as  I 
know  no  one  has  as  yet  performed  symphysiotomy  under  the  circum- 
stances. 

Brow  Presentations. — In  brow  presentations  the  head  occupies  a  posi- 
tion midway  between  flexion  and  extension:  hence  the  portion  situated  be- 
tween the  orbital  ridge  and  large  fontanelle  presents  at  the  superior  strait. 


Fig.  268. — Diagram  shotting  Direc- 
tion of  Pressure  in  Conversion 
of  A  Face  into  a  Vertex  Pres- 
entation by  Thorn's  Mance  cvre. 


254 


OBSTETRICS 


As  nearly  every  child  which  is  born  by  the  face  has  gone  through  a  pre- 
liminary stage  of  brow  presentation,  the  latter  must  occur  quite  as  fre- 
quently as  that  of  the  face,  later  undergoing  spontaneous  conversion  into 


Fig.  269. — Diagram  showing  Position  of 
Child  in  Left  Anterior  Brow  Pres- 
entation. 


Fig.  270. — Diagram  showing  Position  of 
Child  in  Eight  Posterior  Brow  Pres- 
entation. 


either  a  face  or  a  vertex  presentation.  It  is  generally  stated  that  persistent 
brow  presentations  occur  once  in  every  1,500  to  1,750  cases,  though  von 
Weiss  observed  one  example  in  every  1,000  cases. 

The  causes  of  this  presentation,  which  have  been  carefully  studied  by 
Ahlfeld,  are  practically  identical  with  those  giving  rise  to  face  presenta- 
tions, and  depend  upon  any  factor  which  interferes  with  flexion  or  pro-' 
motes  extension  of  the  head.  In  twin  pregnancies  not  infrequently  one  or 
both  children  may  present  in  this  manner,  and  Ahlfeld  maintains  that  the 
anterior  surfaces  of  the  two  foetuses  coming  in  contact  mutually  disturb  the 
normal  flexed  attitude,  so  that  extension  is  facilitated.  Usually  the  brow 
is  directed  towards  one  or  other  extremity  of  the  right  oblique  diameter  of 
the  superior  strait,  and  accordingly  the  left  anterior  and  right  posterior 
varieties  are  the  ones  most  frequently  encountered. 

Diagnosis. — The  presentation  can  be  recognised  by  palpation  and  vagi- 
nal touch,  though  the  data  obtainable  from  the  first  are  not  so  char- 
acteristic as  in  the  more  common  presentations.  The  condition  of  affairs 
is  found  to  be  very  similar  to  that  observed  in  face  presentations,  except 
that  the  cephalic  prominence  is  less  marked  on  the  side  of  the  back,  while 
the  resistance  offered  by  the  chin  can  be  felt  on  the  same  side  as  the  small 
parts.  On  vaginal  touch  the  frontal  and  the  anterior  portion  of  the  sagittal 
suture  are  encountered  in  one  of  the  oblique  diameters,  at  one  end  of  which 
the  large  fontanelle  or  the  portion  of  the  skull  just  posterior  to  it  may  be 
felt;  while  at  the  other  the  orbital  ridges,  the  root  of  the  nose,  and  the  eyes 
may  be  distinguished.  Ordinarily  it  is  not  possible  to  palpate  the  mouth 
or  chin,  for  when  these  are  within  reach  we  have  to  deal  with  a  face  pres- 
entation. 

Mechanism. — The  mechanism  of  labour  in  brow  presentations  differs 
materially  with  the  size  of  the  foetus.     Ahlfeld  and  most  observers  have 


MECHANISM    OF    LABOUR    IN    BUoW    PRESENTATIONS 


255 


stated  that  this  is  most  frequently  below  the  normal;  whereas  Weiss  main- 
tains that  large  children  are  the  rule.  In  the  former  case  the  course  of 
labour  as  a  rule  is  quite  easy,  while  in  the  latter  it  is  usually  very  difficult. 
The  cause  of  the  difficulty  is  apparent  when  we  consider  that  the  diameter 

<<l'  i  he  head  which  must  engage  at  the  superior  strait  is  the  mento-occipital, 
and  that  engagement  is  therefore  impossible,  unless  the  child  is  of  small 
size,  until  after  marked  moulding  has  taken  place,  by  which  ilm  inenlo- 
occipital  diameter  has  become  diminished  and  the  fronto-occipital  increased 
in  length. 

After  moulding  and  descent  have  occurred  the  brow  usually  rotates  an- 
teriorly, and  the  forehead,  orbital  ridges,  and  root  of  the  nose  appear  at 
the  vulva.  One  of  the  superior  maxillary  bones  then  becomes  stemmed 
against  the  inferior  margin  of  the  symphysis,  and  the  rest  of  the  head  is 
born  by  a  movement  of  extreme  flexion,  the  brow,  bregma,  and  occiput  ap- 
pearing in  succession  over  the  anterior  margin  of  the  perinaeum.  After 
the  birth  of  the  occiput,  the  mouth  and  chin  descend  from  behind  the 
pubic  arch  by  a  movement  of  extension.  In  other  words,  we  have  a 
mechanism  somewhat  similar  to  that  observed  in  the  less  frequent  mode 
of  delivery  in  the  case  of  posterior  occiput  presentations,  which  have  ro- 
tated into  the  hollow  of  the  sacrum. 

As  has  already  been  pointed  out,  a  large  child  cannot  enter  the  birth 
canal  without  considerable  moulding  of  the  head.  This  adds  materially  to 
the  length  of  labour  and  results  in  the 
birth  of  children  with  characteristically 
deformed  heads.  The  caput  is  found 
over  the  forehead  and  extends  from  the 
orbital  ridges  to  the  large  fontanelle, 
and  in  many  cases  is  so  marked  as  to 
render  diagnosis  by  vaginal  touch  al- 
most impossible.  In  these  cases,  as  is 
shown  in  Fig.  271,  the  forehead  is  very 
prominent  and  square,  the  mento-oc- 
cipital  diameter  being  diminished  and 
the  fronto-occipital  diameter  increased 
in  length. 

Pro;/ 11  os is. — The  outlook  in  persist- 
ent forms  of  brow  presentation  is  gen- 
erally considered  to  be  bacljmless  the  foetus  be  small.  In  the  transient 
varieties,  of  course,  it  depends  upon  the  presentation  which  ultimately 
results,  and  whether  the  face  or  vertex  enters  the  birth  canal. 

Rational  methods  of  treatment,  and  more  particularly  stricter  attention 
to  aseptic  technique,  have  led  to  a  marked  improvement  in  the  prognosis. 
Thus  Ahlfeld,  Fritsch,  and  Budin  (1873-'76)  collected  34  cases  with  2 
maternal  and  7  foetal  deaths,  4  of  which  were  directly  due  to  the  presenta- 
tion. Weiss,  on  the  other  hand,  has  recently  reported  29  cases  from 
Braun's  clinic  in  Vienna,  without  a  death  of  foetus  or  mother. 

Treatment. — If  the  brow  be  recognised  at  the  superior  strait,  the  treat- 
ment will  vary  according  as  the  presentation  promises  to  he  transient  or 


Fig.  271. — Diagram  showing  Configura- 
tion or  Head  in  Brow  Presentation 
(American  Text-Book). 


256  OBSTETRICS 

persistent.  The  former  should  be  left  alone  if  the  brow  be  anterior,  as  it 
"will  become  converted  into  a  mento-anterior  presentation,  and  the  child 
will  probably  be  born  spontaneously .  On  the  other  hand,  if  the  presenta- 
tion appears  to  be  persistent,  and  even  in  transient  cases  with  the  brow 
posterior,  attempts  at  conversion  should  be  made  before  the  head  has 
undergone  any  great  degree  of  moulding — that  is,  as  soon  as  the  first  stage 
of  labour  is  completed.  If  the  brow  be  directed  posteriorly  it  is  occasion^ 
ally  possible  to  substitute  an  occipito-anterior  presentation  by  pushing  up 
the  presenting  part  with  the  fingers  in  the  vagina,  while  at  the  same  time 
attempts  are  made  to  flex  the  child's  body  with  the  external  hand.  If  these 
manipulations  are  not  successful,  version  should  be  performed,  as  recom- 
mended in  face  presentations.  If  the  brow  be  directed  anteriorly,  we  have 
the  choice  between  conversion  into  a  face  presentation  by  vaginal  manoeu- 
vres, or  internal  podalic  version  followed  by  immediate  extraction.  Person- 
ally I  am  in  favour  of  the  latter  procedure,  which  should  always  be  employed 
when  attempts  at  manual  conversion  fail.  If  the  brow  be  well  engaged  and 
firmly  fixed,  conversion  should  not  be  attempted  unless  one  is  able  to 
push  the  presenting  part  up  to  the  level  of  the  superior  strait,  when  the 
treatment  is  identical  with  that  outlined  above.  But  if  this  cannot  be 
accomplished,  the  case  should  be  left  to  nature,  and  forceps  applied  when 
indicated  by  the  condition  of  the  mother  or  child.  It  should  be  remem- 
bered, however,  that  delivery  under  these  circumstances  is  nearly  always 
associated  with  considerable  injury  to  the  maternal  soft  parts,  owing  to  the 
large  circumference  of  the  foetal  head  by  which  they  are  distended.  Wal- 
lich  has  made  an  earnest  plea  for  the  performance  of  symphysiotomy  in 
persistent  brow  presentations,  and  has  reported  7  operations  with  no  ma- 
ternal and  only  2  fcetal  deaths. 

Breech  Presentations. — As  has  already  been  pointed  out,  the  relation 
between  the  lower  extremities  and  buttocks  of  the  child  is  not  alwavs  the 


Fig.  272.— Diageaii  showing  Position  of  Child  Fig.  273— Diageaii   showing   Position  of 

in  L.  S.  I.  A.  Child  in  R.  S.  I.  A. 

same  in  sacro-iliac  presentations,  and  we  therefore  distinguish  between 
frank  breech,  complete  breech,  foot  and  knee  presentations.     In  all  these 


First  manoeuvre. 


Second  manoeuvre. 


'j 


S 


Third  manoeuvre. 


[N*LE 


Fourth  manoeuvre. 


PALPATION   IN  LEFT   SACEO-ILIAC-ANTERIOR  PRESENTATION. 


MECHANISM  OF  LABOUR    IX   BRBECE    PRESENTATIONS 


•>:, 


varieties,  however,  the  mechanism  of  labour  is  essentially  the  same,  so  that 
they  need  not  be  considered  separately. 

Normally  the  breech  engages  in  such  a  manner  thai  the  bitrochanteric 
diameter  occupies  the  right  oblique  diameter  of  the  superior  strait,,  and 


Yur.  -J74. — Fbozen  Section,  Latter  Part  of  Pregnancy,  Child  ix  L.  S.  I.  T.     Waldeyer). 


accordingly  the  right  sacro-iliac  anterior  and  left  sacro-iliac  posterior  are 
the  presentations  niost  frequently  observed. 

In  100,000  cases  of  labour,  Pinard  observed  3,301  breech  presenta- 
tions— about  3.33  per  cent.  These  statistics  include  premature  as  well  as 
full-term  labours,  but  if  the  latter  alone  are  considered,  we  find  one  in  62 
cases. 

Diagnosis. — On  palpation,  the  first  nianceuvre  reveals  a  hard,  round; 
ballottable  body  occupying  the  fundus  of  the  uterus,  and  when  the  ab- 
dominal walls  are  very  thin  one  can  occasionally  obtain  a  characteristic- 
crackling  sensation  offered  by  the  bones  of  the  skull.  By  the  second 
manoeuvre  the  back  is  found  to  occupy  one  side  of  the  abdomen  and  the 
small  parts  the  other,  position  and  variety  being  determined  by  the  loca- 
tion of  the  former.  On  the  third  manoeuvre,  if  engagement  has  not  oc- 
curred, the  irregular  breech  is  freely  movable  above  the  superior  strait: 
while,  if  it  has  already  occurred,  the  fourth  manoeuvre  shows  that  the  pelvis 
is  filled  by  a  soft  mass  which  interferes  with  the  penetration  of  the  fingers 
into  its  cavity  (Plate  XIII). 

On  vaginal  examination  the  diagnosis  is  made  by  recognising  the  char- 
acteristic portions  of  the  breech.     Generally  speaking,  one  can  feel  both 


258  OBSTETRICS 

tubera  ischii,  the  sacrum  with  its  spines  and  the  anus,  and  when  further 
descent  has  occurred  the  external  genitalia  may  he  distinguished.  In 
many  cases,  especially  where  labour  is  prolonged,  the  buttocks  become 
markedly  swollen,  so  that  differentiation  between  the  face  and  breech  may 
be  rendered  very  difficult,  as  the  anus  may  be  mistaken  for  the  mouth,  and 
the  ischial  tuberosities  for  the  malar  bones.  Care  in  examination,  however, 
should  prevent  this  error,  for  when  the  finger  is  introduced  into  the  anus 
it  experiences  a  muscular  resistance,  whereas  in  the  mouth  the  firmer, 
more  unyielding  jaws  would  be  felt.  Again,  on  removing  the  finger,  it  is 
not  infrequently  found  to  be  stained  with  meconium,  which  could  never 
occur  with  a  face  presentation.  The  most  accurate  information,  however, 
is  obtained  from  the  sacrum  and  its  spine^  for  when  these  are  felt  the 
diagnosis  of  position  and  variety  is  established. 

In  complete  breech  presentations,  the  feet  may  be  felt  alongside  of  the 
buttocks,  and  in  footling  presentations  one  or  both  feet  may  hang  down 
into  the  vagina.  In  the  latter  case,  one  can  readily  determine  which  foot 
is  encountered  by  bearing  in  mind  the  relation  of  the  great  toe.  When  the 
breech  has  descended  deeper  into  the  pelvic  cavity,  the  genitalia  may  be 
felt,  and  if  these  are  not  deformed  by  an  effusion  of  serum,  it  is  possible  to 
diagnose  the  sex  of  the  foetus.  Only  under  such  circumstances  can  we  feel 
certain  as  to  this  j)oint  before  delivery. 

The  f  cetal  heart  sounds  are  heard  through  the  back  of  the  child,  usually 
at  the  level  of  the  umbilicus  or  slightly  above  it. 

2Etiology. — The  causes  of  breech  presentations  are  manifold.  Accord- 
ing to  the  experiments  of  Schatz  the  foetus,  when  suspended  in  liquor 
amnii,  always  sinks  by  its  buttocks,  so  that  if  gravity  were  the  only  factor 
concerned,  breech  presentations  would  be  the  most  frequent  of  all.  As  a 
matter  of  fact,  however,  this  is  by  no  means  the  case. 

In  the  later  months  of  pregnancy  head  presentations  result  from  a 

process  of  accommodation  between  the  foetal  ovoid  and  the  uterus;  but  in 

j I  the  earlier  months  these  factors  do  not  so  readily  come  into  play,  and 

/breech  presentations  are  accordingly  much  more  common  than  at  term. 

tThey  also  occur  very  frequently  in  twin  pregnancies  and  in  cases  of  hy- 
dramnios,  inasmuch  as  the  increased  distention  of  the  uterus  interferes 
/  with  accommodation,  when  gravity  causes  the  breech  to  descend.  Accord- 
,  ing  to  Pinard's  statistics,  59  per  cent  of  all  breech  presentations  occur  in 
^multipara3,  in  whom  the  flaccidity  of  the  uterine  and  abdominal  walls  plays 
/a  part  in  their  production.  Their  occurrence  is  also  favoured  by  the  pres- 
jftence  of  any  obstacle  which  opposes  the  engagement  of  the  head,  as  in 
L/ contracted  pelves,  excessive  size  of  the  normal  head,  or  hydrocephalus. 

Jleclianism. — Unless  there  be  some  disproportion  between  the  size  of 
the  child  and  the  pelvis,  engagement  and  descent  readily  occur  in  one  of 
the  oblique  diameters  of  the  pelvis,  the  anterior  hip  being  directed  toward 
one  ilio-pectineal  eminence,  and  the  posterior  hip  towards  the  opposite 
sacro-iliac  synchondrosis.  When  the  latter  encounters  the  resistance  of 
the  pelvic  floor,  internal  rotation  usually  occurs  and  brings  the  anterior  hip 
to  the  pubic  arch,  the  bitroehanteric  diameter  of  the  child  coming  into 
relation  with  the  antero-posterior  diameter  of  the  pelvic  outlet.    Eotation 


MECHANISM  OF   LABOUR   IN    BREECH   PRESENTATIONS 


259 


usually  takes  place  from  the  ilio-pectineal  eminence  to  the  pubis  through 
an  arc-  of  !•'■  degrees;  but  in  a  small  proportion  of  cases,  particularly  when 
the  posterior  extremity  is  prolapsed,  it  may  occur  in  the  opposite  direction, 
the  posterior  hip  rotating  past  the  sacrum  and  through  the  opposite  half 
of  the  pelvis— i.  <-..  through  an  arc  of  225  degrees. 

After  rotation,  descent  continues  until  the  perinasum  is  distended  by 
the  advancing  breech,  while  the  anterior  hip  appears  at  the  vulva  and.  is 
stemmed  against  the  pubic  arch.  By  a  movement  of  lateral  flexion  of  the 
body,  the  posterior  hip  is  then  forced  over  the  anterior  margin  of  the  peri- 
mvum.  which  retracts  upward  over  the  child,  thus  allowing  its  bodv  to 
straighten  out,  when  the  anterior  hip  is  born.  The  legs  and  feet  follow 
the  breech  and  may  he  horn  spontaneously,  although  not  infrequentlv  the 
aid  of  the  obstetrician  is  required.     After  the  birth  of  the  breech  a  move- 


Fig.  275. — Diagp.au  showi>-&  Direction  or  Lsteexai.  Rotation-  i>-  E.  S.  I.  P.  Position". 


ment  of  external  rotation  occurs,  as  a  result  of  which  the  shoulders  are 
brought  into  relation,  with  one  of  the  oblique  diameters  of  the  pelvis. 
They  then  descend  rapidly  and  undergo  internal  rotation,  the  bisacromial 
diameter  now  corresponding  with  the  antero-posterior  diameter  of  the 
inferior  strait.  The  shoulders  are  followed  by  the  head,  which  descends 
sharply  flexed  upon  the  thorax.  Immediately  following  their  birth  a  second 
movement  of  external  rotation  occurs,  which  serves  to  bring  the  neck  under 
the  symphysis  pubis,  after  which  the  head  is  born  in  a  position  of  flexion, 
the  chin,  mouth,  nose,  forehead,  bregma,  and  occiput  appearing  in  succes- 
sion over  the  perinaeum  (Figs.  276  and  ■???). 

In  a  small  number  of  cases  rotation  occurs  in  such  a  manner  that  the 
back  of  the  child  is  directed  towards  the  vertebral  column,  instead  of 
towards  the  abdomen  of  the  mother.  Under  such  circumstances  the  face 
appears  under  the  symphysis  pubis,  and  the  head  is  born,  the  face,  brow, 
and  finally  the  occiput  slipping  down  under  it.  It  is  of  the  utmost  im- 
portance to  remember  that  if  premature  traction  be  emploved  the  head 
18 


260 


OBSTETRICS 


may  become  extended,  when  its  delivery  can  only  be  accomplished  by  the 
operation  of  extraction. 

Prognosis.— So  far  as  the  life  of  the  mother  is  concerned,  the  prognosis 
differs  but  slightly  in  breech  and  vertex  presentations,  except  that  with  the 
former  labour  is  slower  and  more  liable  to  be  complicated  by  perineal 


Fig.  27fi. — Birth  of  Head  in  Breech  Presentation. 


tears,  which  not  infrequently  extend  through  the  sphincter  ani  muscle. 
The  prognosis  for  the  child,  on  the  other  hand,  is  considerably  worse  than 
in  vertex  presentations,  the  foetal  mortality  being  generally  estimated  at 
about  10  per  cent.  This  figure  applies  to  primiparous  women,  but  a  some- 
what lower  percentage  obtains  when  all  classes  of  cases  are  taken  into 
consideration.  It  is  not  so  high  in  multiparous  women,  for  owing  to  the 
greater  relaxation  of  the  soft  parts  the  child  is  more  readily  expelled  spon- 
taneously, and  when  extraction  becomes  necessary  it  is  more  readily  ac- 
complished. Porak  states  that  1  child  in  9  succumbs  in  the  former  class 
of  cases,  and  only  1  in  30  in  the  latter. 

The  sombre  prognosis  for  the  child  is  due  to  several  factors.  In  the 
first  place,  after  the  breech  is  born  as  far  as  the  umbilicus,  the  cord  is 
exposed  to  a  greater  or  lesser  degree  of  compression  between  the  head 
and  the  pelvic  brim.  It  is  usually  stated  that  not  more  than  eight  minutes 
can  elapse  between  the  birth  of  the  umbilicus  and  the  delivery  of  the  head, 
if  the  child  is  to  be  born  alive,  while  asphyxiation  may  occasionally  occur  at 
an  earlier  period. 

Not  infrequently  foetal  death  is  due  to  the  premature  separation  of 
the  placenta,  for  if  the  delivery  is  not  promptly  effected  after  the  head  has 
passed  into  the  lower  part  of  the  birth  canal,  the  partially  emptied  uterus 
may  retract  to  such  an  extent  as  to  separate  the  placenta  from  its  walls,  and 
thus  put  a  stop  to  the  utero-placental  circulation. 

In  primiparous  women,  where  considerable  resistance  is  offered  by  the 


MECHANISM  OF  LABOUR  IN  BREECH  PRESENTATIONS 


261 


pelvic  soft  parts,  spontaneous  delivery  of  the  head  is  often  unavoidably 
delayed  and  foetal  death  results,  unless  the  child  be  extracted  manually. 
In  all  eases  of  breech  presentation,  therefore,  the  obstetrician  should  be 
prepared  to  render  prompt  assistance  if  .Nature  shows  herself  unable  to 
fulfil  her  task. 

Treatment. —  In  view  of  the  serious  fecial  prognosis  attending  breech 
presentations,  the  obstetrician  should  aim  to  prevent  their  occurrence  as 
far  as  possible,  and  whenever  they  are  diagnosed  in  the  later  weeks  of 
pregnancy,  an  at  tempt  should  he  made  to  substitute  a  vertex  presentation 
by  means  of  external  version.  This  is  readily  accomplished  in  multiparas 
with  lax  abdominal  walls,  but  is  much  more  difficult  in  primiparse.  After 
the  substitution  has  been  effected,  the  child  should  be  held  in  its  new 
position  by  a  properly  fitting  bandage  until  engagement  of  the  head  occurs, 
for  if  this  precaution  be  not  taken  it  is  not  unusual  for  the  child  to  revert 
to  its  original  position.  External  version  may  also  be  attempted  in  the 
first  stage  of  labour,  provided  the  breech  has  not  descended  deeply  into 
the  pelvis;  but  when  it  has  once  become  fixed,  all  such  efforts  are  unavail- 
ing, and  it  is  best  to  leave  the  case  to  nature  and  be  prepared  to  inter- 
fere when  necessary. 

In  many  cases  spontaneous  delivery  occurs,  and  the  attitude  of  the 
obstetrician  is  merely  one  of  expectancy;  nevertheless,  he  should  always 
hold  himself  in  readiness  to  intervene  at  a  moment's  notice.     For  this 


Fig.  277. — Birth  of  Head  in  Breech  Presentation. 


reason,  as  soon  as  the  breech  appears  at  the  vulva,  the  patient  should  be 
brought  to  the  edge  of  the  bed  in  order  that  not  a  moment  may  be  lost  in 
performing  extraction  should  it  become  necessary.  At  the  same  time  every- 
thing required  for  the  resuscitation  of  the  asphyxiated  child  should  be 
ready  for  instant  use.     It  is  most  important  to  remember  that  labour  is 


262  OBSTETRICS 

materially  facilitated  by  the  arms  retaining  their  normal  crossed  position 
over  the  thorax,  as  well  as  by  sharp  flexion  of  the  head.  This  is  best 
attained  by  firm  downward  pressure  upon  the  fundus,  which  should  be 
maintained  by  the  nurse  or  an  assistant,  so  that  the  obstetrician  can  keep 
his  hands  clean  for  any  emergency. 

Owing  to  the  fact  that  the  breech  forms  a  less  efficient  dilating  wedge 
than  the  head,  care  should  be  taken  to  prevent  premature  rupture  of  the 
membranes  and  the  escape  of  the  amniotic  fluid.  For  this  reason  among 
others,  as  few  internal  examinations  as  possible  should  be  made.  Generally 
speaking,  the  frank  breech  forms  a  better  dilating  wedge  than  the  complete 
breech,  inasmuch  as  it  allows  a  closer  application  to  the  margins  of  the 
partially  dilated  os.  On  the  other  hand,  if  interference  becomes  necessary, 
the  complete  breech  offers  more  satisfactory  conditions  for  immediate  de- 
livery, as  a  foot  can  readily  be  brought  down  and  used  as  a  tractor,  so  that 
the  question  arises  whether  it  might  not  be  better  in  the  former  class  of 
cases  to  make  it  a  rule  to  bring  down  one  or  both  feet  proplrylactically. 
Usually  this  is  not  advisable,  unless  some  abnormality  exists  on  the  part  of 
the  mother  or  child  which  renders  it  probable  that  prompt  delivery  may  be 
called  for.  In  such  cases  a  foot  should  be  brought  down  by  Pinard's 
manoeuvre  as  soon  as  the  membranes  rupture.  The  technique  of  this 
manipulation,  as  well  as  the  rules  for  extraction,  will  be  considered  in 
Chapter  XXI. 

LITERATURE 

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Baudelocque.     L'art  des  accouehemens,  1789,  t.  ii,  36-40. 

Boer.     Sieben  Biicher  iiber  naturliche  Geburtshiilfe,  Wien,  1834,  96. 

Budix.     De  la  tete  du  foetus  au  point  de  vue  de  l'obstetrique.     Paris,  1876. 

Davis.     The  Management  of  Face  Presentations.    Medical  News,  July  14,  1894. 

Deleurye.     Traite  des  accouehemens,  etc.     Paris,  1770. 

Duncan.     On  the  Production  of  Presentation  of  the  Face.     Mechanism  of  Natural  and 

Morbid  Parturition.     Edinburgh,  1875,  218-231. 
Fieux.     line  observation  de  presentation  primitive  de  la  face.     Comptes  rendus  de  la 

Soc.  d'Obst.,  de  Gyn.  et  de  Psed.,  1900,  ii,  225-231. 
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Hecker.     Ueber  die  Schadelform  bei  Gesichtslagen.     Berlin,  1869. 
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Lachapelle.     Pratique  des  accouehemens,  1821,  t.  i,  382. 
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Ribemoxt-Dessaignes.     Precis  d'obstetrique,  1894,  427. 
Schatz.     Die  Umwandlung  von  Gesichtslagen  zu  Hinterhauptslagen  dureh  alleinigen 

ausseren  Handgriff.     Archiv  f.  Gyn.,  1873,  v,  306-331. 
Ueber  den  Schwerpnnkt  der  Frucht.     Centralbl.  f.  Gyn.,  1900,  Nr.  40,  1033-1036. 
Spiegelberg-Wiexer.     Lehrbuch  der  Geburtshiilfe,  II.  AufL,  1891,  172. 
Thorn.     Zur  manuellenUmwandlnng  der  Gesichtslagen  in  Hinterhauptslagen.     Zeitsehr. 

f.  Geb.  u.  Gyn.,  1886,  xiii,  186-220. 
Die  Stellung  der  manuellen  Umwandlung  in   der  Therapie  der  Gesichts-  und  Stirn- 

lagen.     Volkmann's  Sammlung  klin.  Vortrage,  1902,  Nr.  339. 
Wallich.     De  la  symphyseotomie  dans  les  presentations  persistantes  du  front.     Comptes 

rendus  de  la  Soc.  d'Obst.,  de  Gyn.  et  de  Pasd.,  1902,  iv,  18-34. 


MECHANISM    OE    LABOUR   IN   BREECH    PRESENTATIONS  263 

Wuss.     /in-  Ii.-li.-iiidlun-  der  Gesichts- und   Stirnlagen.     Volkmann's  Sammlu klin. 

Vortrage,  X.  P.,  Nr.  74. 
Winckel.     Zur  Lehre  von  dm  Gesichtslagen.     Klinische  Beobachtungen  zur  Pathologie 

der  Geburt.     Rostock,  L869,  59-65. 
Zeller.     Bemerkungen  iiber  einige  Gegenstande  aus  der  praktischen  Entbindungskunsl 

W'ini.  1797. 

Zwelfel.    Lehrbuch  der  Geburtshiilfe.     III.  Aufl.,  177. 


CHAPTEE  XIV 

PHYSIOLOGY  OF  LABOUR  {Continued) 

PHYSIOLOGY    AND    MANAGEMENT    OF    THE    THIRD 
STAGE    OF    LABOUR 

Situation  of  the  Placenta  in  Utero. — The  older  authors  believed  that 
the  placenta  was  usually  implanted  at  or  in  the  immediate  neighbourhood 
of  the  fundus.  The  researches  of  Schroecler,  Pinard,  Ahlfeld,  Leopold, 
Holzapfel,  and  others,  however,  have  shown  that  this  is  by  no  means  the 
rule,  but  that  the  most  common  situation  is  on  the  anterior  or  posterior 
wall  of  the  uterus,  occasionally  on  its  lateral  wall,  and  only  in  exceptional 
instances  upon  the  fundus.  Fig.  278,  which  represents  a  vertical  section 
through  the  uterus  at  term,  shows  the  usual  mode  of  attachment.  As  a 
rule  the  lower  margin  of  the  placenta  lies  somewhat  above  the  internal 
os,  for  when  it  impinges  upon  or  overlaps  the  latter  we  have  to  deal  with 
a  pathological  condition — placenta  prasvia. 

Mechanism  of  Separation  of  the  Placenta. — Under  normal  conditions 
the  placenta  remains  fixed  to  the  uterine  wall  until  after  the  birth  of  the 
child,  and  becomes  separated  from  it  only  during  the  third  stage  of  labour. 
While  the  first  and  second  stages  are  proceeding,  the  uterine  contractions 
bring  about  a  sligbtdecrease  in  area  of  the  surface  to  which  it  is  attached, 
and  in  its  attempt  at  accommodation  the  placenta  becomes  slightly  folded 
upon  itself,  its  margins  being  somewhat  rounded  and  prominent.  At  the 
same  time,  however,  it  is  pressed  firmly  a.o-ainst  the  uterine  wall  by  the 
amniotic  fluid,  through  which  the  intra-uterine  pressure  is  transmitted; 
otherwise  it  is  probable  that  premature  separation  would  be  the  rule  and 
not  the  exception. 

After  the  expulsion  of  the  child,  the  contraction  and  retraction  of  the 
uterus  leads  to  a  considerable  thickening  of  its  walls,  with  a  correspond- 
ing decrease  in  the  size  of  its  cavity,  as  well  as  to  a  rapid  lessening  in  the 
area  of  the  placental  site.  Eventually  the  disproportion  becomes  so  great 
that  the  inner~portion  o'f  the  glandular  layer  of  the  decidua  is  torn 
through,  and  the  placenta  and  membranes  are  separated  from  the  walls  of 
the  uterus  and  come  to  lie  free  in  its  cavity,  whence  they  are  expelled 
by  further  contractions  into  the  lower  uterine  segment  or  the  upper  por- 
tion of  the  vagina. 

After  its  extrusion,  the  maternal  surface  of  the  placenta  still  retains 
a  thin  covering  of  decidua,  which  represents  the  atrophic  compact  layer 
264 


M'ODE   OF    INTRUSION    OP   THE    PLACENTA 


265 


and  the  innermosi   portion  of  the  spongy  layer  of  the  decidua  serotina, 
which  must  be  stripped  off  in  order  to-reach  tlie  chorionic  villi. 

Mode  of  Extrusion  of  the  Placenta. — As  early  as  1789  Baudelocque  had 
described  two  ways  in  which  the  placenta  could  be  extruded  from  the 
uterus.  Thus,  separation  from  the  uterine  wall  could  commence  either  at 
the  centre  of  the  placenta  or  at  a  point  in  its  circumference.  "In  the 
first  case,  the  middle  of  the  placenta  being  pushed  forward  by  an  effusion 

of  blood  beneath  it,  the  organ  be- 
comes inverted  upon  itself  in  such 
a  manner  that  it  presents  by  its  foe- 
tal surface,  which  is  covered  by  the 
membranes  and  vessels.  .  .  .  But 
when  the  placenta  becomes  de- 
tached  below,    particularly   if   the 


Fig.  278.  —  Diagram  showing  Relation  of 
Placenta  to  Uterine  Wall  in  Latter 
Part   of  Pregnancy.     X  %■ 


Fig.  279. — Diagram  showlng  Eelation  of  Pla- 
centa to  Uterine  Wall  in  Second  Stage 
of  Labour  (modified  from  Schroeder).    X  K- 


loosening  begins  at  a  point  in  the  neighbourhood  of  the  internal  os,  the 
mechanism  is  entirely  different,  for  the  afterbirth  becomes  rolled  upon  itself 
in  the  form  of  a  cylinder,  whose  long  axis  corresponds  to  that  of  the 
uterus,  in  such  a  manner  that  it  presents  its  detached  maternal  surface  to 
the  examining  finger,  and  its  exit  is  alwavs  preceded  by  a  small  amount  of 
fluid  blood." 

These  ideas  seem  to  have  excited  but  little  interest  until  1865,  when 


266 


OBSTETRICS 


Schultze  advanced  the  opinion  that  the  placenta  was  usually  expelled  by  the 
first  method  described  by  Baudelocque.  This  belief  remained  practically 
undisputed  until  1871,  when  Matthews  Duncan  contended  that  the  second 
was  the  more  frequent  and  normal  mechanism.  The  active  discussion 
aroused  by  this  statement,  although  it  led  to  no  final  settlement  of  the 
question,  had  the  effect  of  directing  more  earnest  attention  to  the  physi- 
ology of  this  stage  of  labour. 

The  two  methods  are  now  designated  by  the  names  of  Schultze  and 
Duncan  respectively.  In  the  former,  separation  begins  first  at  the  cen- 
tral portion  of  the  placenta,  between  which  and  the  uterine  wall  more 
or  less  blood  is  poured  out,  which  gradually  increases  in  amount  until  a 
retro-placental  hgematoma  of  considerable  size  is  formed,  which  eventually 


Fig.  280. — Frozen   Section,  Third    Stage    of    Labour,    showing    Twin    Placentae    in    Utero 

(Pestalozza).     X  %■ 


brings  about  the  complete  separation  of  the  organ  from  its  site  of  attach- 
ment, while  the  membranes  still  remain  adherent.  The  placenta  then 
presents  at  the  internal  os  by  its  foetal  surface  and  passes  through  the 
opening  in  the  membranes,  dragging  them  after  it;  it  is  then  expelled  from 
the  vulva,  its  foetal  or  amniotic  surface  first,  and  the  now  inverted  mem- 
branes following  after.  In  this  mechanism  there  is  no  escape  of  blood 
until  after  the  extrusion  of  the  placenta  (Figs.  281  and  282). 

In  Duncan's  method,  on  the  other  hand,  the  placenta,  after  its  separa- 
tion from  the  uterine  wall,  becomes  folded  upon  itself  and  its  lower  margin 
presents  at  the  internal  os.  It  then  traverses  the  vagina  and  emerges  from 
the  vulva  by  one  margin,  the  membranes  being  sometimes,  but  by  no  means 
always,  inverted.     When  expulsion  occurs  in  this  manner,  there  is  slight 


MODE   OF   EXTRUSION   OF   THE    PLACENTA 


-'■■7 


but  continuous  haemorrhage  from  the  birth  of  the  child  until  the  placenta 
is  delivered  (Fig.  "383). 

With  respect  to  the  relative  frequency  with  which  these  two  mechan- 


Fig.  2S1. — Diagram  illustrating  Extrusion  of  Placenta  by  Schultze's  Mechanism. 


Fig.    252. — Diagraii    illustrating    Later    Stage    in    the    Extrusion    of    the    Placenta    bt 

>chultze*s  Mechanism. 

isms  occur,  there  has  been  much  discussion.    In  this  country  and  in  Eng- 
land, Duncan's  views  are  commonly  accepted,  and  it  is  generally  held  that 


268 


OBSTETRICS 


Schultze's  method  borders  on  the  abnormal.  In  Germany  the  opinions  are 
still  very  conflicting,  Olshausen  and  A^eit  stating  that  Duncan's  method 
occurs  in  the  majority  of  cases,  whereas  Schroeder  held  that  the  reverse 
was  the  case.  Moreover,  the  statistics  brought  forward  by  various  authors 
would  seem  to  render  the  matter  still  more  uncertain.  Thus  Zeigler,  writing 
under  the  inspiration  of  Fehling,  states  that  he  observed  Duncan's  mechan- 
ism in  83.6  per  cent  of  his  cases,  whereas  in  79.76  per  cent  of  Ahlfeld's 
cases  that  of  Schultze  was  noted. 

Holzapfel,  in  a  recent  monograph,  has  given  details  and  a  full  literature 
dealing  with  the  present  status  of  the  question,  and,  as  the  result  of  very 
interesting   experiments   and   observations,   concludes   that   the   placenta 


Fig.  283. — Diagram  illustrating  Extrusion  ojf  Placenta  by  Duncan's  Mechanism. 


nearly  always  presents  at  the  internal  os  by  Duncan's,  but  leaves  the  uterus 
by  Schultze's  mechanism. 

Although  it  is  difficult  to  reconcile  the  contradictory  statements  of  the 
various  observers,  it  would  appear  justifiable  to  class  both  mechanisms  as 
perfectly  normal,  that  of  Duncan  occurring  most  often  when  the  placenta 
is  situated  in  the  lower  portion  of  the  uterus,  that  of  Schultze  when  it  is 
situated  in  the  upper  portion. 

Clinical  Picture  of  the  Third  Stage  of  Labour. — Immediately  following 
the  birth  of  the  child,  the  remainder  of  the  amniotic  fluid  escapes,  after 
which  there  is  usually  a  slight  flow  of  blood.  The  uterus  can  now  be  felt 
as  a  firm,  hard  mass,  the  fundus  lying  a  few  centimetres  below  the  um- 
bilicus. For  a  short  time  the  patient  experiences  no  pain,  but  after  a  few 
minutes  uterine  contractions  begin  again  and  recur  at  regular  intervals, 
until  the  placenta  becomes  separated  and  is  expelled  into  the  lower 
uterine  segment. 

At  some  time,  varying  between  five  and  thirty  minutes  after  the  birth 


CLINICAL'   PICTURE  OP  THE  THIRD  STAGE  OP   LABOUR 


-.;■.. 


of  the  child,  careful  palpation  shows  that  the  fundus  of  the  uterus  has 
risen  3  to  5  centimetres  above  its  original  position,  while  simultaneously 


Fig.  iis-1. — Abdomen  immediately  aftek  Biktii  uf  Child. 


-Abdomen  of  Same  Patient,  showing  rising  up  of  Fundus  following  Extrusion  of 

the  Placenta  into  the  Loweb  Utep.ine  Segment. 


a  slight  prominence  has  appeared  immediately  above  the  symphysis  pubis 
(Figs.  284  and  285).     This  change  indicates  that  the  placenta  has  become 


270  OBSTETRICS 

detached  and  has  been  extruded  from  the  uterine  cavity  proper  into  the 
lower  uterine  segment,  or  even  into  the  upper  part  of  the  vagina.  In  rare 
cases  the  placenta  is  born  almost  immediately  after  the  child,  but  as  a  rule 
not  until  fifteen  to  thirty  minutes  later,  while  occasionally  hours  may  pass 
before  it  appears  at  the  vulva.  The  possibility  of  wide  divergence  in  this 
respect  can  readily  be  appreciated  when  we  remember  that  the  action  of  the 
uterus  ceases  after  the  placenta  has  been  extruded  from  its  cavity,  so  that  its 
further  descent  depends  partly  upon  gravity,  but  principally  upon  the  con- 
tractions of  the  abdominal  muscles.  But  owing  to  the  great  distention  to 
which  the  latter  have  been  subjected,  their  tonicity  is  frequently  so 
impaired  that  they  can  no  longer  exert  sufficient  force  to  expel  the  after- 
birth from  the  vagina,  so  that  in  many  cases  it  will  not  be  born  for 
hours  unless  the  patient  assumes  a  sitting  position  or  assistance  is  ren- 
dered by  the  physician.  Ahlfeld  has  stated  that  spontaneous  termina- 
tion of  the  placental  period  occurred  in  only  13.6  per  cent  of  his  cases, 
even  when  he  waited  for  one  and  a  half  to  two  hours  after  the  birth  of 
the  child. 

The  average  loss  of  blood  during  the  third  stage  of  labour  is  esti- 
mated at  about  400  cubic  centimetres,  a  constant  but  slight  flow  occurring 
throughout  the  entire  period  when  the  placenta  is  delivered  by  Duncan's  j 
mechanism,  and  a  sudden  gush  of  blood  immediately  following  its  expul-/ 
sion  by  Schultze's  mechanism.  ' 

Management  of  the  Third  Stage  of  Labour. — Up  to  1861  the  manage- 
ment of  the  third  stage  of  labour  varied  greatly,  and  delivery  of  the 
placenta  was  effected  either  by  traction  upon  the  cord  or  by  passing  the 
hand  into  the  vagina  or  uterus,  as  the  case  might  be,  and  bringing  it  away. 
Both  of  these  methods,  but  more  particularly  the  latter,  as  will  be  ex- 
plained later,  are  necessarily  attended  by  grave  dangers. 

In  1861,  Crede  described  what  he  considered  the  ideal  method  of  de- 
livering the  placenta,  which  was  somewhat  as  follows:  Immediately  after 
the  exit  of  the  child,  the  obstetrician  grasps  the  uterus  with  his  hand,  and 
after  waiting  from  five  to  ten  minutes,  gently  kneads  it,  thereby  stimulat- 
ing it  to  contract.  The  hand  is  then  applied  to  the  abdomen  in  such  a 
manner  that  the  thumb  rests  upon  the  anterior  and  the  fingers  upon  the 
posterior  surface  of  the  uterus,  and  as  soon  as  a  contraction  occurs,  firm  and 
steady  pressure  should  be  made  downward  in  the  axis  of  the  superior 
strait. 

The  introduction  and  routine  employment  of  Crede's  method  of  ex- 
pression undoubtedly  marked  a  most  important  advance,  inasmuch  as  by 
doing  away  with  the  necessity  for  traction  upon  the  cord  and  the  frequent 
manual  removal  of  the  placenta,  it  has  saved  the  lives  of  thousands  of 
women.  With  certain  modifications  it  is  now  generally  employed  through- 
out the  world.  As  a  matter  of  history,  Jellett  has  noted  that  the  method, 
while  usually  ascribed  to  Crede,  had  been  practised  for  many  years  pre- 
viously at  the  Botunda  Hospital  in  Dublin. 

In  opposition  to  the  expression  of  the  placenta  immediately  after  the 
birth  of  the  child,  Dohrn,  Ahlfeld,  and  others  stated  that  a  greater 
amount  of  blood  is  lost  during  the  third  stage,  and  that  there  is  a  greater 


MANAGEMENT   OF   THE   TIIIKI>   ST  A  UK   OF   LABOUR 


271 


tendency  to  post-partum  haemorrhage  than  when  the  extrusion  of  the 
placenta  is  left  to  Nature,  or  expression  is  resorted  to  only  after  an  inter- 
val of  several  hours,  lint,  while  it  must  be  recognised  as  incontrovertible 
that  too  early  a  resort  to  Crede's  method  is  harmful,  inasmuch  as  it  de- 
feat- the  very  purpose  for  which  it  is  employed  and  interferes  with  the 
physiological  separation  of  the  placenta,  the  arguments  adduced  in  favour 
of  waiting  so  long  a  time  appear  to  be  neither  satisfactory  nor  rational. 
It  is  difficult  to  see  what  advantages  are  to  be  gained  by  delaying  expres- 


Fig.  286. — Expression  of  Placenta. 


sion  after  the  placenta  has  once  become  detached  from  its  original  site  and 
lies  in  the  lower  uterine  segment,  especially  if  Ahlfeld's  statement  is 
correct  that  spontaneous  delivery  will  occur  only  in  13  to  14  per  cent  of 
the  cases  at  the  end  of  two  hours.  On  the  other  hand,  there  are  certainly 
very  obvious  objections  to  any  unnecessary  prolongation  of  the  third  stage 
of  labour.    For  the  patient  a  delay  of  several  hours  between  the  birth  of  the 


272  OBSTETRICS 

child  and  the  completion  of  labour,  means  much  additional  discomfort  and 
an  increased  risk  of  infection;  while  the  busy  physician  can  ill  afford  the 
expenditure  of  valuable  time,  unless  he  be  convinced  that  by  such  per- 
sonal sacrifice  he  can  better  insure  the  well-being  of  his  patient. 

In  normal  cases,  therefore,  attempts  at  expression  should  not  be  made 
until  the  placenta  has  been  spontaneously  expelled  into  the  lower  uterine 
segment  or  upper  portion  of  the  vagina;  but  as  soon  as  this  has  taken 
place  there  is  no  reason  why  the  process  should  not  be  hastened.  In  my 
own  clinic  the  following  procedure  has  been  adopted  with  most  satis- 
factory results:  As  soon  as  the  child  is  born  the  hand  is  laid  upon  the 
abdomen,  and  if  the  uterus  can  be  felt  as  a  firm,  hard,  globular  mass  it  is 
left  alone.  On  the  other  hand,  if  it  appears  to  be  soft  and  flaccid,  it  is 
gently  kneaded  until  firm  contractions  are  induced.  The  condition  of 
the  uterus  is  then  carefully  watched,  the  hand  being  applied  to  it  at  fre- 
quent intervals,  but  kneading  is  carried  out  only  when  necessary.  In 
the  majority  of  cases,  after  a  lapse  of  ten  or  fifteen  minutes,  it  "is  noticed 
that  the  fundus  rises  up  4  to  5  centimetres  above  the  position  which  it 
has  just  occupied,  but  at  the  same  time  remains  firm  and  hard.  This 
change  indicates  that  the  placenta  has  become  separated  from  the  uterine 
wall  and  has  been  expelled  into  the  lower  uterine  segment  or  the  upper 
portion  of  the  vagina.  Attention  was  first  directed  to  this  point  by 
Pinard,  Schroeder,  and  Cohn,  but  its  importance  has  not  been  generally 
recognised.  The  placenta  is  now  expelled  by  grasping  the  uterus  and 
making  downward  pressure  in  the  axis  of  the  superior  strait,  using  the 
uterus  merely  as  a  piston  to  shove  the  placenta  downward  and  outward. 
When  the  latter  appears  at  the  vulva  it  should  be  grasped  by  the  hand 
and  the  membranes  gently  twisted  into  a  cord,  so  as  to  prevent  their  being 
torn  off  from  the  margins  of  the  placenta,  after  which  they  are  slowly 
extracted. 

In  most  cases  the  placenta  can  be  expressed  in  this  manner  within  half 
an  hour  after  the  birth  of  the  child;  but  if  the  fundus  does  not  rise  up 
spontaneously  by  the  end  of  that  period,  the  typical  Crede  method  should 
be  resorted  to.  The  modification  of  the  original  procedure,  here  recom- 
mended, leaves  the  separation  of  the  placenta  from  the  uterine  wall  abso- 
Iutely  to  Nature,  and  simply  expresses  it  after  it  has  been  spontaneously 
xpelled  from  the  uterine  cavity. 

Not  infrequently  small  portions  of  the  membranes  may  be  left  behind 
in  utero  or  in  the  vagina.  If  the  ends  be  outside  the  vulva,  they  should 
be  seized  and  the  remnants  delivered  by  gentle  traction;  but  otherwise  it 
is  advisable  to  leave  them  alone  and  to  allow  them  to  be  cast  off  with  the 
lochia,  rather  than  to  introduce  the  fingers  into  the  vagina  or  uterus  in 
the  attempt  to  remove  them. 

Immediately  following  the  birth  of  the  placenta,  the  uterus  should  be 
palpated  again;  normally  it  is  found  firmly  contracted  and  retracted,  and 
if  it  remains  so,  there  is  no  danger  of  haemorrhage.  But,  on  the  other 
hand,  if  it  shows  any  tendency  towards  relaxation,  it  should  be  kneaded 
until  it  contracts.  There  is  usually  no  danger  of  relaxation  and  consequent 
haemorrhage,  provided  no  signs  of  it  appear  during  the  first  hour  after 


MANAGEMENT  OF  THE  THIRD  STAGE  OF   LABOUR  273 

the  extrusion  of  tin-  placenta.  Accordingly,  the  condition  of  the  uterus 
should  be  carefully  watched  during  this  period  by  the  physician  or  nurse. 
lint,  even  when  this  duty  is  delegated  to  the  Latter,  the  physician  should 
remain  at  the  house  of  the  patienl  for  one  hour,  so  as  to  be  on  hand  in 
case  an  emergency  should  arise. 

( Occasionally,  the  amount  of  blood  lost  immediately  following  the  birth  of 
the  child  may  be  so  great  as  to  render  imperative  the  prompt  delivery  of  the 
placenta,  and  under  such  circumstances  expression  should  be  employed 
at  once.  Under  all  other  conditions,  however,  we  should  watch  for  the 
rising  up  of  the  fundus  before  resorting  to  this  procedure. 

As  soon  as  the  placenta  and  membranes  are  born  they  should  be  care- 
fully inspected  for  the  purpose  of  ascertaining  whether  the  structures  have 
been  expelled  entire,  or  whether  portions  have  been  left  behind  in  the 
uterus.  If  they  are  perfectly  intact,  all  is  well;  but  if  the  maternal 
surface  of  the  placenta  shows  defects  which  are  not  clue  to  mere  tears 
of  its  substance,  but  which  appear  to  indicate  that  a  considerable  part 
has  been  left  behind,  the  hand  should  be  carefully  redisinfected,  a  sterile 
rubber  glove  put  on,  and  the  retained  portion  removed  manually,  since  if 
allowed  to  remain  in  the  uterus  it  nearly  always  gives  rise  to  haemorrhage. 

In  rare  cases  it  may  be  found  impossible  at  the  end  of  half  an  hour  to 
expel  the  placenta  by  means  of  Crede's  method,  and  under  such  circum- 
stances, unless  the  condition  of  the  patient  be  serious,  or  there  be  free 
haemorrhage,  the  obstetrician  should  wait  patiently  and  repeat  his  attempts 
at  expression  at  intervals,  and  should  not  despair  of  eventual  success  until 
at  least  two  hours  have  elapsed.  Under  such  circumstances,  it  is  probable 
that  abnormal  adhesions  exist  between  the  placenta  and  the  uterine  wall 
which  require  a  longer  time  than  usual  for  their  separation.  In  any  case, 
manual  removal  of  the  organ  must  never  be  undertaken  unless  absolutely 
necessary,  as  it  is  a  more  serious  procedure  than  the  application  of  forceps 
or  the  performance  of  version.  In  the  former  the  hand,  which  is  rarely 
perfectly  sterile,  is  introduced  between  the  placenta  and  the  uterine  wall, 
and  comes  in  direct  contact  with  the  freshly  wounded  placental  site,  through 
which  are  scattered  numerous  thrombosed  vessels  which  afford  a  most  ex- 
cellent culture  medium  for  bacteria;  whereas  in  the  latter,  the  hands  or 
instruments  are  introduced  into  the  amniotic  cavity,  so  that  whatever 
micro-organisms  may  have  been  carried  up  by  them  are  likely  to  be  cast  off 
with  the  afterbirth. 

For  particulars  concerning  the  technique  of  manual  removal  of  the 
placenta,  the  reader  is  referred  to  the  section  on  obstetrical  operations. 


LITERATURE 

Ahlfeld.     Abwartende  Method e  oder  Crede'scher  Handgriff  ?    Leipzig.  1888. 

Ueber  die  ersten  Vorgange  bei  der  phvsiologischen  Losung  der  Placenta.     Zeitsehr.  f. 

Geb.  u.  Gyn..  1895.  xxxiii.  418-442. 
"Weitere  Untersnchnngen  fiber  die  physiolog.  Vorgange  der  Nachgeburtsperiode.     Zeit- 
sehr. f.  Geb.  u.  Gyn„  1897.  xxxvi.  448-466. 
Baudelocque.     De  la  delivranee  naturelle.     L'art  des  accouehemens,  1789.  t.  i.  413-415. 


274  OBSTETRICS 

Cohn.     Zur  Physiologie  und  Diatetik  tier  Nachgeburtsperiode.     Zeitschr.  f.  Geb.  u.  Gyn., 

1886,  xii,  381-417. 
Crede.     Ueber  die  zweckmassigste  Methotle  tier  Entfernung  tier  Nachgeburt.    Monatsschr. 

f.  Geburtskunde,  1861,  xvii,  274-292. 
Ueber  die  zweckmassigste  Methode  tier  Entfernung  der  Xachgeburt.     Archiv  f.  Gyn., 

1881,  xvii,  260-280. 
Dohrn.     Zur  Behandlung  der  Nachgeburtsperiode.     Deutsche  med.  Wochenschr.,  1880, 

Nr.  41. 
Die  Behandlung  des  Nachgeburtszeitraumes.     Jena,  1898. 
Duncan.     The  Expulsion  of  the  Placenta.     (Read  to  the  Edinburgh  Obstetrical  Society, 

March  22,  1871.)     Mechanism  of  Natural  and  Morbid  Parturition.     Edinburgh,  1875, 

246-256. 
Holzapfel.     Ueber  den  Placentarsitz.    Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1898,  i,  286-337. 
Ueber  die  Losung  und  Ausstossung  der  Nachgeburt.    Hegar's  Beitrage  zur  Geb.  u.  Gyn., 

1899,  ii,  413-481. 
Jellett.     The  Dublin  Method  of  Effecting  the  Delivery  of  the  Placenta.     Dublin  Jour. 

Med.  Science,  June,  1900. 
Leopold.     Die  Diagnose  des  Placentarsitzes  in  der  Schwangerschaft  und  wahrend  der 

Geburt.     Arbeiten  aus  der  koniglichen  Frauenklinik  in  Dresden,  1895,  ii,  151-166. 
Olshausen-Veit.     Schroeder's  Lehrbuch  der  Geburtshiilfe,  XIII.  Aufl.,  1899,  175. 
Pinard.     Du  palper  pendant  la  tlelivrance  normale.     Traite  du  palper  abdominal,  2me 

ed.,  Paris,  1884,  241-253. 
Pinard  et  Varnier.     Etudes  d'anatoinie  obstetricale  normale  et  pathologique.   Paris,  1892. 
Schroeder.      Beitrage   zur    Physiologie    der    Austreibungs-   und    Nachgeburtsperiode, 

Der  Zeitschr.  f.  Geb.  u.  Gyn.,  1885,  xi,  421. 
Schroeder  und  Stratz.     Zur  Physiologie  der  Austreibungs-  und  Nachgeburtsperiode. 

schwangere  und  kreissende  Uterus,  Berlin,  1886,  75-112. 
Schultze.     Wandtafeln  zur  Schwangerschaft  und  Geburtskunde.     Leipzig,  1865. 

Ueber  den  Mechanismus  tier  spontanen  Ausscheidung  der  Nachgeburt,  etc.     Deutsche 

med.  Wochenschr.,  1880,  Nr.  51,  252. 
Ziegler.     Beitrage  zum  Mechanismus  der  physiologischen  Placentarlosung.     D.  I.,  Halle. 

1895. 


CHAPTEK  XV 
CONDUCT  OF  NORMAL  LABOUR 

As  a  rule  the  services  of  the  obstetrician  are  engaged  some  time  before 
the  expected  dale  of  confinement,  in  order  that  the  patient  may  be  under 
medical  supervision  for  at  least  the  last  few  months  of  pregnancy. 

The  importance  of  a  careful  preliminary  examination,  not  later  than 
four  to  six  weeks  before  term,  has  already  been  insisted  upon.  This  can 
be  more  conveniently  carried  out  with  the  patient  at  home  and  in  bed, 
when  the  obstetrician  should  take  careful  measurements  of  the  pelvis, 
determine  the  presentation  and  position  of  the  child,  and  acquaint  himself, 
not  only  with  any  abnormality  which  may  exist  in  the  generative  tract, 
but  also  with  the  general  physical  condition.  At  the  time  of  this  visit 
also  it  is  well  to  give  the  patient  a  list  of  such  articles  as  may  be  needed 
at  the  time  of  labour  and  during  the  puerperium,  and  which  she  is  ex- 
pected to  supply.  The  physician  should  also  communicate  with  the  nurse 
in  order  to  make  sure  that  she  understands  the  preparations  which  fall 
to  her  share.  Experience  has  taught  me  that  the  only  way  by  which  mis- 
takes can  be  avoided  is  to  have  all  necessary  directions  written  down  in 
black  and  white,  or  preferably  to  use  printed  cards  containing  definite  and 
concise  instructions  for  the  patient  and  nurse. 

Preparations  for  labour  on  the  Part  of  the  Patient  and  Nurse. — At 
the  time  of  the  preliminary  examination,  the  physician  should  inspect  the 
room  which  is  to  be  used  for  the  confinement  and  make  necessary  sug- 
gestions as  to  its  arrangement.  He  should  also  inquire  as  to  the  number 
of  wash-basins  which  are  available;  for  with  the  increasing  perfection  of 
plumbing  the  ordinary  wash-basin  and  pitcher  are  often  replaced  by  per- 
manent wash-stands,  so  that  in  the  homes  of  the  well-to-do  it  is  sometimes 
difficult  to  find  a  sufficient  number  for  disinfecting  the  hands  and  cleansing 
the  patient.  Five  basins  will  be  needed:  four  for  the  use  of  the  physician 
and  one  for  the  patient;  and  if  so  many  are  not  already  in  the  house,  a 
sufficient  number,  made  of  plain  agate-ware  and  measuring  10  inches 
across  the  top,  should  be  procured. 

The  patient  should  also  be  instructed  to  provide  herself  with  a  bed- 
pan, a  2-quart  fountain  syringe  for  rectal  enemata,  15  yards  of  non- 
sterilized  gauze  and  2  pounds  of  cotton  batting,  for  making  bed-pads,  * 
or  6  prepared  sanitary  bed-pads  and  2  pieces  of  rubber  sheeting,  one 
1X2  yards  and  the  other  f  XI  yard.  The  following  articles  should  be 
19  275 


276 


OBSTETRICS 


obtained  from  the  druggist  at  least  one  month  before  the  expected  date 
of  confinement,  so  that  they  may  be  in  readiness  in  case  labour  should 
occur  unexpectedly: 


100  cubic  centimetres  Squibb's  chloroform, 
4  ounces  potassium  permanganate, 
8       "       oxalic  acid, 
4       "       boric  acid, 
1  ounce  tube  of  green  soap, 
1      "      tube  of  vaseline, 


100  Bernays's  bichloride  tablets, 
8  ounces  alcohol, 
2  drams  ergotol, 

1  nail-brush, 

2  pounds  absorbent  cotton. 


If  one  has  a  large  obstetrical  practice,  it  is  advisable  to  have  some 
reputable  druggist  arrange  and  keep  in  stock  a  box  containing  the  above- 
mentioned  articles,  so  that  the  patient  can  be  told  simply -to  buy  an  ob- 
stetrical outfit. 

The  nurse  should  see  that  a  sufficient  number  of  bed  and  vulval  pads 
are  prepared  in  advance.  A  week  or  ten  days  before  the  expected  date 
of  confinement  she  should  sterilize  a  portion  of  them,  together  with  5 
packages  containing  the  following  articles:  Six  towels  or  diapers  (2  pack- 
ages), 1  sheet,  half  a  pound  of  absorbent  cotton,  and  cotton  pledgets  or  gauze 
sponges.  At  the  commencement  of  labour  she  should  prepare  2  large  pitch- 
ers of  boiled  water,  one  of  which  should  be  kept  hot,  while  the  other  is 
allowed  to  cool,  the  top  being  carefully  covered  with  a  sterile  towel. 

Preparations  on  the  Part  of  the  Physician.— When  the  physician  ex- 
pects to  be  called  to  an  obstetrical  case,  he  should  hold  himself  in  readiness 
to  respond  promptly  at  any  hour  within  two  Aveeks  of  the  expected  date 
of  confinement.  If  he  is  obliged  to  leave  town  about  that  time,  he  should 
notify  the  patient  and  arrange  for  a  competent  substitute  to  take  his  place 
if  necessary.  He  should  also  remember  that  the  proper  care  of  such  cases 
requires  a  great  deal  of  time,  and  frequently  no  small  sacrifice  of  personal 
convenience,  and  if  he  is  not  willing  to  place  himself  at  the  disposal  of  his 
patients,  as  far  as  may  be  necessary,  he  should  refuse  to  attend  them.  Un- 
due haste  is  one  of  the  most  frequent  causes  of  unsatisfactory  results  in 
this  branch  of  medicine. 

The  physician  should  provide  himself  with  an  obstetrical  outfit,  which 
should  be  neatly  packed  in  an  appropriate  box  or  valise  and  be  kept  ready 
for  immediate  use.  It  should  contain  not  only  the  instruments  which  he 
may  need,  but  also  the  various  drugs  required  for  hand  disinfection,  an- 
aesthesia, and  the  usual  emergencies,  as  well  as  a  certain  number  of  sterile 
towels  and  dressings,  in  case  the  patient  has  failed  to  provide  herself  with 
such  materials,  and  for  sudden  calls  or  consultations.  The  obstetrical 
valise  should  contain  a  pelvimeter,  a  pair  of  nail-clippers  and  a  nail- 
cleaner,  chloroform,  permanganate  of  potash,  oxalic  acid,  bichloride  tab- 
lets, green  soap,  and  a  nail-brush,  1  ounce  of  ergotol  or  fluid  extract  of 
ergot,  tablets  of  sodium  chloride  for  preparing  normal  salt  solution,  and 
a  hypodermic  syringe  with  the  usual  tablets.  There  should  also  be  a 
chloroform  inhaler,  a  suit  of  white  clothes,  three  packages  containing  re- 
spectively 6  sterile  towels  and  a  sheet,  sterilized  absorbent  cotton,  and 
several  sterilized  roller  gauze  bandages  for  packing  the  uterus  and  vagina., 


PREPARATIONS    I'oK    LAHnl'R 


l'77 


ns  well  as  a  small  jar  of  sterile  vaseline.     Glass  tubes  containing  sterile 
catheters,  silk  and  silkwdrm-gul  sutures,  and  bobbhi  for  tying  the  cord  are 

also  needed,  as  well  as  a  Kelly  obstetrical  pad  and  a  Leg-bolder. 


Fig.  287. — Obstetrical  Bag. 


The  following  instruments  for  repairing  perineal  and  cervical  lacera- 
tions should  be  sterilized  and  wrapped  in  a  package  ready  for  instant  use: 
A  pair  of  scissors,  a  needle-holder,  1  artery  clamps,  dissecting  forceps, 
long  dressing  forceps,  bullet  forceps,  a  three-bladecl  or  a  Simon  speculum, 
and  an  assortment  of  needles.  The  valise  should  also  contain  a  tin  box, 
40  X  13  X  10  centimetres,  provided  with  a  lid  and  wooden  handles.  In 
this  the  various  instruments  can  be  packed  when  not  in  use,  and  at  opera- 
tion it  serves  as  a  boiler  and  as  a  receptacle  for  them  after  sterilization.  A 
Tarnier  axis-traction,  or  an  ordinary  Simpson  forceps,  should  be  carried, 
according  as  the  physician  has  become  accustomed  to  the  one  or  other 
instrument,  as  well  as  a  3-quart  fountain  syringe  with  a  glass  nozzle  for 
intra-uterine,  and  a  hollow  needle  for  subcutaneous  injections  of  salt  solu- 
tion. The  latter  should  be  sterilized  in  advance  and  wrapped  in  a  sterile 
towel,  so  as  to  be  ready  for  immediate  use. 

This  list  does  not  include  the  instruments  required  for  the  destructive 
operations,  as  they  are  not  usually  carried  by  the  general  practitioner. 
Everything  mentioned  in  the  above  list  may  be  packed  into  a  box  21  X 
S±  X  S  inches. 

Conduct  of  the  First  Stage  of  labour. — The  physician  should  instruct 
the  patient  as  to  the  best  method  of  communicating  with  him  without 
delay;  but  generally  speaking,  should  direct  the  nurse  not  to  send  for  him 
if  the  labour  commences  at  night,  between  lip.  m.  and  7  a.  m.,  unless  it 


278  OBSTETRICS 

seems  necessary  that  he  should  see  the  patient  at  once.  On  the  other 
hand,  when  the  pains  begin  between  7  a.  m.  and  11  p.  m„  the  physician 
should  be  notified  immediately,  so  that  he  may  make  his  plans  accord- 
ingly. 

As  soon  as  the  nature  and  severity  of  the  pains  indicate  that  labour 
has  set  in,  the  patient  should  receive  a  full  bath  and  a  rectal  enema. 
When  the  physician  arrives  he  should  make  a  careful  external  examina- 
tion, map  out  the  presentation  and  position  of  the  child,  and  listen  to  the 
foetal  heart.  In  primiparse,  if  the  pelvis  be  normal,  and  the  child  present 
by  the  vertex,  which  is  firmly  engaged,  there  is  no  necessity  for  making 
an  internal  examination,  provided  that  the  heart  sounds  are  in  good  con- 
dition, as  all  that  can  be  gained  therefrom  is  information  concerning  the 
degree  of  dilatation  of  the  cervix.  On  this  point  one  can  usually  form  a 
fairly  accurate  idea  from  the  behaviour  of  the  patient  and  the  extent  to 
which  the  head  has  descended  into  the  pelvis,  which  can  usually  be  deter- 
mined by  external  palpation.  Again,  the  rupture  of  the  membranes  and 
the  onset  of  bearing-down  jDains  usuall}*  indicate  the  beginning  of  the  sec- 
ond stage,  after  which,  as  a  rule,  there  is  ample  time  in  primipara?  for 
the  arrival  of  the  physician. 

In  general,  then,  it  may  be  said  that  in  primipara?,  if  no  abnormality 
be  suspected,  an  internal  examination  is  unnecessary  and  should  not  be 
made  unless  the  first  stage  is  unduly  prolonged.  On  the  other  hand,  in 
view  of  the  fact  that  in  multiparous  women  the  first  stage  is  frequently 
very  short,  and  the  second  occasionally  terminating  with  a  few  expulsive 
pains,  unless  the  physician  is  prepared  to  remain  in  the  house  indefinitely, 
it  may  be  desirable  to  ascertain  the  condition  of  the  cervix  by  vaginal 
touch,  as  the  patient  should  not  be  left  after  the  external  os  is  two  thirds 
dilated. 


Frequent  internal  examinations  should  be  avoided  for  two  reasons:  to 
minimize  the  possibility  of  infection  and  to  save  the  feelings  of  the  patient 
as  far  as  possible. 

Hand  Disinfection. — Eecent  experimental  work  has  conclusively  dem- 
onstrated that  it  is  impossible,  in  a  large  proportion  of  cases,  at  any  rate, 
to  render  the  hands  absolutely  sterile,  no  matter  what  method  of  disin- 
fection may  be  employed.  Even  after  the  most  rigorous  directions  have 
been  scrupulously  followed,  there  still  remains  a  not  inconsiderable  dan- 
ger of  infection.  For  details  concerning  the  latest  work  upon  the  subject 
the  reader  is  referred  to  Haegler's  monograph. 

With  the  view  of  still  further  minimizing  these  risks,  the  use  of  rubber 
gloves  has  been  introduced.  These  can  be  rendered  perfectly  sterile  by 
boiling,  and  when  drawn  over  the  carefully  disinfected  hands  afford  the 
greatest  safety  possible.  Since,  however,  they  are  liable  to  tear  occasion- 
ally, the  necessity  for  disinfecting  the  hands  before  putting  them  on  is 
apparent.  But  that  their  employment,  even  in  conjunction  with  all  our 
other  precautions,  does  not  entirely  do  away  with  the  possibility  of  intro- 
ducing bacteria  into  the  genital  tract,  is  evident,  since  I  have  shown  that 
pathogenic  organisms  are  present  upon  the  inner  surfaces  of  the  labia  and 
the  margins  of  the  hymen  in  at  least  60  per  cent  of  pregnant  women,  and 


HAND  DISINFECTION  279 

that  the  mere  introduction  of  a  sterilized  glass  speculum  2  centimetres  in 
diameter,  which  is  no  larger  than  the  two  fingers  employed  for  examina- 
tion, carries  micro-organisms  into  the  vagina  in  at  Leasl  one  half  of  such 
cases.  Moreover,  inasmuch  as  the  delicate  structure  of  the  parts  renders 
their  thorough  disinfection  out  of  the  question,  and  as  the  examining 
fingers  necessarily  come  in  contact  with  them,  it  musl  be  admitted  that 
vaginal  examinations  during  Labour  can  never  be  entirely  devoid  of  dan- 
ger, and  they  should  therefore  be  avoided  so  far  as  is  consistent  with  the 
welfare  of  the  patient.  While  these  considerations  should  not  deter  us 
from  making  as  many  examinations  as  may  be  necessary  in  abnormal  cases, 
it  should  always  be  borne  in  mind  that  the  best  results  are  obtained  by  the 
least  possible  employment  of  the  vaginal  touch  and  the  widest  possible 
utilization  of  external  methods  of  examination. 

If  the  hands  of  the  physician  have  recently  come  in  contact  with 
infectious  material  at  operation  or  autopsy,  labour  should  be  conducted  by 
external  examinations  alone,  vaginal  examinations  being  made  only  in  the 
presence  of  some  abnormality,  and  then  only  after  most  careful  disinfec- 
tion and  the  use  of  gloves. 

In  all  cases,  before  making  an  internal  examination,  the  hands  should 
be  disinfected  as  carefully  as  for  a  major  surgical  operation.  The  best 
method  for  this  purpose,  introduced  by  Dr.  Halsted  some  years  ago,  and 
described  by  Dr.  Kelly  in  1891,  consists  of  the  following  steps: 

1.  Cut  the  finger-nails  with  clippers  or  scissors  to  1  millimetre  in 
length. 

2.  Scrub  the  hands  and  forearms  up  to  the  elbows  vigorously  with 
nail-brush,  green  soap,  and  hot  water,  for  at  least  live  minutes  by  the 
clock,  and  longer  if  they  are  not  macroscopic-ally  clean,  paying  particular 
attention  to  the  nails  and  palmar  surface  of  the  fingers.  The  water  must 
be  changed  at  least  once.  After  changing  it,  remove  dirt  from  beneath 
the  finger-nails  with  nail-cleaner  or  knife  and  renew  the  washing. 

3.  Rinse  the  hands  in  fresh  water  and  then  soak  them  in  a  hot  satu- 
rated solution  of  potassium  permanganate  until  they  take  on  a  deep  ma- 
hogany-brown colour. 

4.  Dissolve  this  off  in  a  hot  saturated  solution  of  oxalic  acid. 

o.  Then  soak  the  hands  and  forearms  in  a  l-to-1.000  bichloride  solu- 
tion for  at  least  three  minutes  by  the  clock. 

6.  Touch  nothing  until  ready  to  examine  the  patient,  going  directly 
from  the  bichloride  to  her. 

The  only  objection  which  can  be  made  to  this  method  of  hand  disinfec- 
tion is  the  length  of  time  which  it  requires  and  the  roughness  of  the  hands 
which  sometimes  follows  it.  The  first  objection  cannot  be  overcome,  as  I 
do  not  believe  that  the  hands  can  be  thoroughly  disinfected  in  less  than 
ten  minutes  by  any  method.  The  second  can  be  obviated  to  a  great  ex- 
tent by  anointing  the  hands  with  glycerin  or  some  emollient  after  the 
examination  has  been  made. 

The  rapid  method  of  disinfection  introduced  by  Furbringer.  by  which 
he  believed  that  the  hands  could  be  rendered  absolutely  sterile  in  three 
minutes,  has  been  shown  by  later  experimental  work  to  be  absolutely  unre- 


280 


OBSTETRICS 


liable.  Nor  have  the  recent  methods  of  disinfection  by  means  of  alcohol 
substantiated  the  claims  which  have  been  made  for  them,  inasmuch  as 
Kronig  has  shown  that  they  are  based  upon  a  fallacy,  and  that  alcohol  does 
not  possess  a  markedly  germicidal  action,  but  simply  produces  conditions  in 
the  skin  which  for  the  time  being  render  it  difficult  to  remove  the  organ- 
isms from  its  surface. 

Preparation  of  Patient  for  Examination. — While  the  physician  is  dis- 
infecting his  hands,  the  nurse  should  be  making  her  preparations  for  the 
internal  examination.  The  patient  should  lie  on  the  right  or  left  side  of 
the  bed,  according  as  the  physician  prefers  to  examine  with  his  right  or 
left  hand.  She  should  then  be  covered  with  a  sheet,  which  is  pulled  up 
from  the  foot  of  the  bed  and  its  ends  wrapped  about  the  legs  in  such  a 
manner  as  to  leave  the  external  genitalia  free  with  the  least  possible  ex- 
posure of  the  rest  of  the  person.  The  bedclothes  should  not  be  thrown  back 
so  as  to  leave  the  legs  of  the  patient  exposed.  Nor  should  the  physician  be 
expected  to  examine  under  any  covering.  The  vulva  and  the  inner  surfaces 
of  the  thighs  are  then  thoroughly  washed  with  soap  and  hot  water,  particu- 
lar attention  being  paid  to  the  regions  about  the  anus  and  clitoris.  If  the 
pubic  hairs  are  very  long  they  should  be  cut  short  with  scissors  or  shaved. 
After  a  thorough  cleansing  the  parts  should  be  rinsed  with  fresh  water 


Fig.  288. Showing  proper  Method  of  covering   Patient  with  Sheet  before  making  a 

Vaginal  Examination. 


and  then  sponged  with  a  l-to-2,000  bichloride  solution,  after  which  they 
should  be  covered  with  a  towel  soaked  in  the  same  solution,  which  remains 
in  place  until  the  physician  is  ready  to  commence  his  examination.  Final- 
ly, a  sterile  towel  should  be  placed  under  the  patient's  buttocks,  so  as  to 
prevent  the  examining  hand  from  coming  in  contact  with  the  bed. 


VAGINAL   EXAMINATION 


281 


Method  of  making  a  Vaginal  Examination. — Alter  thorough  disinfec- 
tion, the  thumb  and  forefinger  of  one  hand  distend  the  Labia  widely,  so 
as  to  stretch  the  vaginal  opening  and  prevent  the  examining  fingers  from 
coming  in  contact  with  the  inner  surface  of  the  labia  and  the  margins  of 


Fig.  2S9. — Illustrating  spreading  apart  the  Labia  before  making  a  Vaginal  Examination 


the  hymen,  while  the  index  and  second  fingers  of  the  other  hand  are  anoint- 
ed with  sterile  vaseline  and  introduced  into  the  vagina. 

In  making  the  examination  a  definite  routine  should  be  followed:  1.  The 
fingers  should  be  introduced  along  the  anterior  surface  of  the  vaginal  wall, 
and  the  shape  and  size  of  the  pubic  arch  _  and  the  height  of  the  symphysis 
noted.  2.  The  cervix  should  then  be  examined  in  order  to  determine 
whether  its  canal~is  obliterated,  the  degree  to  which  the  external  os  is  dila- 
ted, and  the  character  of  its  margins.  Xext  we  observe  whether  the  mem- 
branes are  intact  or  not,  great  care  being  taken  to  avoid  rupturing  them  if 
the  patient  is  in  the  first  stage  of  labour.  3.  The  presenting  part  should 
be  felt  for.  and.  if  the  os  be  dilated,  the  presentation  and  position  of  the 
child  should  be  made  out.  It  is  also  important  to  determine  its  relation 
to  the  sjtperior_strait  and  to  the  line  connecting  the  ischial  spines?  37 
After  having  decided  these  points,  the  palmar  surface  of  the  fingers  should 
be  directed  posteriorly,  and  the  perinauvm  palpated  between  the  two  fin- 
gers in  the  vagina  and  the  thumb  outside,  with  special  reference  to  its  con- 
sistency, thickness,  and  resistance.     5.  The  mobility  of  the  coccyx  should 


then  be  tested,  after  which  the  fingers  should  be  passed  upward  over  the 
anterior  surface  of  the  sacrum  and  its  vertical  and  lateral  curvature  noted. 
If  the  presenting  part  is  not  low  down,  the  three  lower  sacral  vertebras 
are  readily  palpable  in  normal  women,  whereas  the  first  and  second  can 


282  OBSTETRICS 

be  felt  only  in  contracted  pelves.  6.  If  the  presenting  part  is  not  deeply- 
engaged,  the  diagonal  conjugate  should  be  measiired. 

If  it  becomes  necessary  to  repeat  the  examination,  exactly  the  same 
rigorous  preparation  is  imperative,  it  being  important  to  remember  that  a 
single  disinfection  of  the  hands  is  efficient  only  for  a  comparatively  short 
period. 

After  completing  the  examination,  the  physician  is  usually  expected  to 
express  an  opinion  as  to  the  probable  course  of  events.  If  everything  is 
normal,  he  should  assure  the  patient  that  all  will  be  well,  but  should 
guard  against  making  any  very  definite  statement  as  to  the  probable  dura- 
tion of  labour,  and  content  himself  with  saying  that  under  such  circum- 
stances the  average  time  is  only  a  certain  number  of  hours,  and  that  her 
suffering  will  probably  be  ended  within  that  period.  The  obstetrician  who 
ventures  to  make  more  precise  statements  will  speedily  find  that  bis 
predictions  are  often  very  faulty,  even  when  the  head  is  on  the  perineum. 
If  some  abnormality  be  present,  it  is  not  always  wise  to  inform  the  patient 
of  the  fact,  but  the  physician  should  be  careful  to  impart  his  knowledge 
to  some  responsible  member  of  the  family  for  his  own  protection,  in  case 
an  emergency  should  arise. 

During  the  first  stage  of  labour  the  patient  usually  prefers  to  move 
about  her  room,  and  frequently  is  more  comfortable  when  occupying  a 
sitting  position.  During  this  period,  therefore,  she  should  not  be  com- 
pelled to  take  to  her  bed  unless  she  feels  so  inclined,  and  when  she  does  so 
she  should  be  cautioned  against  attempting  to  hasten  labour  by  volun- 
tarily bringing  her  abdominal  muscles  into  play,  for  they  have  little  or 
no  effect  upon  the  dilatation  of  the  cervix,  and  the  effort  will  only  serve 
to  exhaust  her  strength. 

Conduct  of  the  Second  Stage  of  Labour. — The  beginning  of  the  second 
stage  of  labour  is  usually  indicated  by  the  rupture  of  the  membranes  and 
the  onset  of  bearing-down  pains,  though  these  signs  are  not  absolutely 
characteristic,  as  in  a  small  number  of  cases  rupture  may  occur  at  an  early 
period,  or  the  patient  may  attempt  to  hasten  the  course  of  labour  by 
making  premature  use  of  her  abdominal  muscles.  On  the  other  hand,  the 
membranes  sometimes  remain  intact  until  they  protrude  from  the  vulva. 
In  still  rarer  cases  they  do  not  rupture  at  all,  the  child  coming  into  the 
world  surrounded  by  them,  or,  as  it  is  popularly  termed,  being  born  with 
a  caul. 

In  the  latter  part  of  the  first  stage  the  pains  generally  become  so 
severe  that  the  patient  naturally  seeks  the  recumbent  position;  but  if  she 
is  still  moving  about  the  room  or  sitting  up,  she  should  go  to  bed  imme- 
diately upon  the  rupture  of  the  membranes  and  the  beginning  of  bearing- 
down  pains. 

Preparation  of  the  Bed. — The  bed  should  be  prepared  as  soon  as  the 
pains  become  severe,  since  in  the  case  of  a  multiparous  woman  the  second 
stage  of  labour  is  often  extremely  short,  and  delivery  occasionally  occurs 
while  the  patient  is  being  moved  from  a  chair  or  sofa  to  the  bed.  A  high  sin- 
gle iron  bedstead  is  preferable,  but  in  private  practice  one  usually  has  to  be 
content  with  the  ordinary  double  bed.  Under  such  circumstances  one  side  of 


COXIHT(T   OF   Till'    SECOND   STAGE   OF    LABOl  l; 


283 


it  should  lie  prepared  lor  the  patient ;  whether  the  right  or  left  depends  upon 
which  hand  the  physician  expects  to  use  for  vaginal  cxaniinat  ion  and  the 
conduct  of  Labour.  A  large  piece  of  rubber  sheel  ing,  1X2  yards,  should  be 
placed  over  the  centre  of  the  mattress,  covering  its  entire  width,  and  over 
this  a  sheet  is  spread.  A  second  piece  of  rubber  sheeting,  f  X  1  yard,  is 
placed  upon  the  side  of  the  bed  upon 
which  the  patient  is  to  lie,  in  such  a 
position  that  it  will  come  directly  un- 
der her  buttocks.  The  entire  bed  is 
then  covered  by  a  draw-sheet;  over 
this  is  placed  a  sterile  bed-pad  upon 
which  the  buttocks  rest,  or  a  Kelly 
obstetrical  rubber  pad  may  be  used. 
With  this  arrangement,  the  upper 
sheet  and  the  small  piece  of  rubber 
cloth  can  be  removed  at  the  comple- 
tion of  labour,  leaving  the  mattress 
protected  hy  a  large  piece  of  rubber 
sheeting  and  the  under  sheet.  To 
avoid  exposure  the  legs  should  be  en- 
cased in  long  leggings  which  reach  to 
the  thighs  and  are  pinned  to  the 
rolled-up  nightgown.  In  winter 
these  should  be  made  of  canton  flan- 
nel and  in  summer  of  thin  muslin. 

Examination  in  the  Second  Stage. 
— After  the  patient  has  been  put  to 
bed,  the  question  arises  whether  or 
not  a  vaginal  examination  should  be  made,  and  this  is  determined  by  the 
condition  of  affairs  in  each  ease.  If  the  head  has  become  engaged  in  the 
first  stage  of  labour,  it  can  be  omitted;  but  if  the  presenting  part  is  not 
engaged,  or  any  abnormality  is  present  or  suspected,  an  internal  examination 
is  absolutely  necessary  in  order  to  ascertain  whether  the  cord  has  prolapsed, 
or  if  everything  is  as  it  should  be. 

If  the  patient  has  apparently  been  in  the  second  stage  of  labour  for 
some  time  without  rupture  of  the  membranes,  an  examination  is  advisable 
in  order  to  determine  the  condition  of  the  cervix;  for,  after  it  has  be- 
come completely  dilated,  the  membranes  have  served  their  purpose  and 
retard  rather  than  hasten  the  birth  of  the  child,  so  that  it  may  be  advisable 
to  rupture  them  artificially.  This  is  usually  readily  accomplished  by  saw- 
ing through  them  with  the  finger-nail,  or  pinching  them  between  the  two 
examining  fingers.  In  rare  instances,  however,  they  are  so  resistant  that 
it  becomes  necessary  to  resort  to  instrumental  means.  For  this  purpose  a 
sterilized  bullet  forceps  is  admirably  suited,  but  if  it  is  not  available,  a  hat- 
pin, previously  heated  in  the  flame  of  an  alcohol  lamp,  is  a  convenient  sub- 
stitute. The  membranes  should  not  be  ruptured  during  the  acme  of  a  pain, 
particularly  when  the  head  is  not  deeply  engaged,  as  occasionally  the  rush 
of  amniotic  fluid  may  be  so  great  as  to  carry  the  cord  along  with  it,  and 


Fig.  290.— Kelly's  Bibber  Pad. 


284  OBSTETRICS 

thus  bring  about  its  prolapse.  The  beginner  should  always  be  careful 
to  differentiate  between  the  distended  membranes  and  a  tense  caput  suc- 
cedaneum. 

When  vaginal  examinations  are  made  in  the  second  stage  of  labour, 
the  same  stringent  precautions  as  to  disinfection  of  the  hands  and  the 
patient's  genitalia  should  be  observed.    When  the  head  is  deeply  engaged 


in  the  pelvis,  internal  examinations  are  quite  unnecessary,  as  its  descent 
can  readily  be  traced  by  the  increasing  difficulty  with  which  the  cephalic 
prominence  is  felt  on  employment  of  the  fourth  manoeuvre.  Moreover, 
when  it  can  no  longer  be  felt  from  above,  if  the  legs  are  widely  separated 
and  the  tips  of  the  fingers  applied  to  the  perinseum,  to  the  side  of  and  in 
front  of  the  anus,  and  pressed  firmly  inward  and  upward,  the  presenting 
part  can  be  felt  as  a  firm,  rounded  body.  Generally  speaking,  this  ma- 
noeuvre becomes  available  as  soon  as  the  head  has  passed  below  the  level 
of  the  ischial  spines. 

During  the  entire  second  stage,  auscultation  should  be  practised  at 
frequent  intervals,  particularly  when  the  head  has  reached  the  pelvic  floor, 
for  occasionally  the  cord  is  pressed  upon  tightly,  and  the  child  may  be 
asphyxiated  at  this  period  and  be  lost,  if  not  delivered  promptly. 

Delivery. — As  soon  as  the  head  can  be  palpated  through  the  perineum, 
preparations  should  be  made  for  delivery.  A  table  should  be  placed  in 
a  convenient  position  at  the  side  of  the  bed,  and  upon  it  a  basin  of  boiled 
water  and  another  of  l-to-2,000  bichloride  solution,  as  well  as  sterilized  cot- 
ton pledgets  or  gauze  sponges,  a  certain  number  of  sterile  towels,  and  the 


CONDUCT  OP  TIIK   SECOND   STAGE  OF   LABOUR 


_- 


material  for  tying  the  cord.  The  instruments  needed  for  the  repair  of  the 
perinaeum  should  also  be  within  easy  reach. 

The  patient  should  then  be  placed  in  position  upon  the  bed.  In  this 
country  it  i-  customary  for  her  to  lie  upon  her  back  with  the  legs  drawn 
up.  though  in  England  ami  many  places  "ii  the  Continent  tin-  lateral  posi- 
tion is  preferred.  If  tin-  leggings  have  nol  been  used,  they  should  now  be 
drawn  up  ami  pinned  to  the  night-gown,  which  has  been  rolled  up  beneath 
the  patient's  back,  so  that  it  may  not  be  soiled.  Tie-  genitalia  should 
again  he  washed  with  soap  and  water,  and  bathed  with  a  bichloride  solu- 
tion. 

After  having  carefully  disinfected  his  hands  so  that  he  may  make  an 
immediate  vaginal  examination  if  necessary,  the  physician  should  place 
a  sterile  towel  beneath  the  patient's  buttocks,  a  second  over  her  abdomen, 
and  others  over  her  legs,  and  pin  them  in  place  so  as  to  cover  everything  in 
the  neighbourhood  of  the  genitalia  with  which  his  hands  may  come  in  con- 
tact, leaving  only  the  vulva  and  perinaeum  exposed. 


Pi...  292. — Showing  Patient   m   Pkopep.   Position    fop.   Deliyert,  axd    covered    by  Steeile 

Deessengs. 


As  the  head  passes  down  into  the  pelvis,  small  particles  of  faeces  are 
frequently  expelled,  and  as  they  appear  at  the  anus  they  should  be  wiped 
away  with  a  piece  of  cotton,  after  which  the  parts  should  be  sponged  off 
with  fresh  pledgets  soaked  in  bichloride  solution. 


286  OBSTETRICS 

As  soon  as  the  head  begins  to  distend  the  vulva  the  patient's  suffer- 
ings become  greatly  increased,  and  are  frequently  excruciating.  At 
this  stage  it  is  advisable  to  begin  to  use  chloroform,  partly  to  relieve 
the  pain,  and  partly  to  aid  in  protecting  the  perinseum.  If  the  nurse  be 
competent,  its  administration  should  be  intrusted  to  her.  The  patient 
having  been  instructed  to  give  notice  as  soon  as  she  feels  a  pain 
beginning,  several  drops  of  chloroform  are  poured  upon  an  Esmarch 
inhaler,  and  she  is  told  to  inspire  deeply.  This  is  repeated  with  each 
pain,  the  inhaler  being  removed  immediately  after  its  cessation.  In  this 
manner,  after  a  short  time  the  sensation  of  pain  becomes  markedly 
diminished,  while  the  patient  retains  consciousness  and  is  generally  able 
to  talk  rationally.  But  when  the  head  begins  to  emerge  from  the  vulva,, 
the  chloroform  should  be  pushed  to  complete  anaesthesia,  during  which 
the  head  is  born.  This  degree,  however,  should  last  only  for  a  few 
moments. 

Protection  of  the  Perinceum. — As  soon  as  the  perinaeum  shows  signs  of 
bulging,  the  physician  should  make  preparations  for  its  protection,  plac- 
ing himself  in  such  a  position  as  to  be  able  effectually  to  check  the  prog- 
ress of  the  head  if  necessary. 

Injuries  to  the  perinseum  are  of  very  frequent  occurrence,  and  can- 
not always  be  avoided  even  under  the  most  skilful  treatment.  The, 
statements  as  to  their  frequency  vary  considerably,  but  all  authorities 
agree  that  they  occur  much  oftener  in  primiparous  than  in  multipa- 
rous  women.  Thus,  Schroeder  observed  them  in  3-1.5  and  9  per  cent 
of  his  cases  respectively;  Balandin  in  25.99  and  4.19  per  cent;  and 
Olshausen  in  21.1  and  1.7  per  cent.  These  figures  would  seem  to  be 
rather  too  conservative,  as  slight  tears  implicating  the  fourchette  occur 
in  from  one  half  to  two  thirds  of  all  primiparas,  and  in  10  per  cent  of 
multiparas.  Occasionally  one  meets  with  physicians  who  state  that 
they  have  delivered  several  thousand  women  with  one  or  two,  or  pos- 
sibly without  a  single  perineal  tear.  Such  statements,  however,  are 
always  erroneous,  and  merely  indicate  that  the  physician  lias  not  inspect- 
ed the  parts  after  labour,  and  designates  as  torn  only  those  cases  in 
which  the  vagina  and  rectum  have  been  converted  into  a  cloaca,  to  the 
existence  of  which  his  attention  would  assuredly  be  called  by  the 
patient. 

In  the  greatest  number  of  cases  the  fourchette  alone  suffers,  but  not 
uncommonly  the  tear  extends  through  a  greater  or  lesser  portion  of  the 
perineal  body  and  is  usually  associated  with  another  extending  some  dis- 
tance up  one  or  both  vaginal  sulci,  while  in  rare  cases  the  entire  perinaeum 
is  torn  through  and  the  rectum  opened  up.  The  first  two  varieties  are 
frequently  unavoidable,  but  the  common  occurrence  of  complete  tears  is 
an  indication  of  ignorance  or  negligence. 

Generally  speaking,  the  causes  of  rupture  are  threefold:  disproportion 
between  the  headend  the  vulva,,  too  rapid  expulsion,  and  ahmnrnalities  in 
the  mechanism  of  labour.  Where  the  head  is  excessively  large  or  the 
vulva  excessively  small,  the  mechanical  conditions  are  such  that  birth  can- 
not take  place  without  a  certain  amount  of  laceration.    In  not  a  few  cases 


PROTECTION   OF  THE   PERINEUM  287 

the  tearing  is  due  not  so  much  to  absolute  disproportion   between  the 
head  and  the  vulva  as  to  the  lack  <>r  « •  1 .- > - 1 i « •  i i \ _ « > i'  tin-  perinaeum,  which  is 

particularly  marked  in  elderly  primipanc     Too  rapid  expulsion,  ho.. 
i-  a  much  more  frequent   cause  of  rupture,  and  when  the  head  is  sud- 
denly and  forcibly  extruded  through  the  imperfectly  distended  vulva,  its 
mode  of  production  is  manifest. 

Various  abnormalities  in  the  mechanism  of  labour  favour  rapture  of 
the  perinaeum.  The  most  frequent  of  these  is  imperfect  extension  of 
the  head,  so  that  the  vulva  is  distended  by  the  occipitofrontal,  instead 
of  the  suboccipito-bregmatic  or  suboccipito-frontal  circumference.  in 
a  certain  number  of  cases  the  presenting  pan  may  be  directed  too  far 
backward — in  other  words,  extension  does,  not  occur — and  under  the  influ- 
ence of  the  uterine  contractions  the  presenting  pari  is  forced  directly 
downward  upon  the  perineal  body,  instead  of  being  guided  upward  and 
forward  towards  the  vulval  opening.  Occasionally  a  similar  condition 
is  observed  in  women  having  a  pelvis  which  approaches  the  male  type,  and 
in  which  the  pubic  arch  is  long  and  narrow,  whereby  the  head  is  prevented 
from  engaging  directly  under  the  symphysis  pubis.  Again,  in  rare  in- 
stances, an  abnormal  inclination  of  the  pelvis,  by  causing  the  vulval  open- 
ing to  look  more  upward  than  usual,  may  bring  about  a  similar  condition. 
In  considering  the  mechanism  of  labour  we  directed  attention  to  the 
factors  which  predispose  to  perineal  rupture,  when  the  head  is  delivered  in  i 
persistent  occipito-posterior  positions,  or  when  the  child  presents  by  the 
brow,  face,  or  breech.  I 

Giffard.  in  1733,  was  the  first  to  direct  attention  to  the  advisability  of 
attempting  to  prevent  perineal  tears.  Numerous  devices  have  since  been 
suggested  having  the  same  object  in  view,  but  their  very  multiplicity 
argues  that  they  are  not  uniformly  satisfactory.  In  most  of  the  older 
methods  pressure  was  applied  directly  to  the  perinaeum,  or  various  at- 
tempts were  made  to  relieve  the  tension  to  which  it  was  subjected,  so 
that  the  physician  was  said  to  support  the  perinaeum.  An  excellent  resume 
of  the  early  literature  upon  the  subject  will  be  found  in  Goodell's  scholarly 
article,  published  in  1871. 

In  the  method  which  has  stood  me  in  best  stead  no  attempt  is  made 
to  support  the  perina?um  by  pressure,  but  the  obstetrician  simply  endeav- 
ours to  favour  extension  of  the  head  and  prevent  it  from  being  suddenly 
extruded  during  the  acme  of  a  pain.  For  this  purpose,  when  the  vertex 
begins  to  distend  the  vulva,  it  should  be  seized  between  the  thumb  and 
three  fingers  of  one  hand,  and  forcible  pressure  made  against  it  during  each 
pain.  At  the  same  time  the  pressure  should  be  directed  in  such  a  manner 
as  to  bring  the  occiput,  and  later  the  nape  of  the  neck,  directly  in  contact 
with  the  inferior  margin  of  the  symphysis,  and  thus  increase  extension. 
Accordingly,  as  soon  as  the  head  appears  at  the  vulva  the  physician  should 
be  ready  to  restrain  its  progress.  He  should  hold  his  hand  in  such  a 
manner  as  to  be  able  to  bring  it  immediately  into  action,  for  in  many 
instances  the  resistance  of  the  vulva  is  unexpectedly  overcome,  and  a  single 
pain  may  be  sufficient  to  push  the  head  suddenly  through  it  with  a  result- 
ing perineal  tear.    After  the  head  is  so  far  born  that  the  vulva  is  distend- 


288 


OBSTETRICS 


ed  by  the  perietal  bosses,  it  may  be  advisable  to  attempt  to  express  it  by 
Ritgen's  method  in  an  interval  between  the  pains.  For  this  purpose,  the 
"paHent  having  been  instructed  to  open  her  mouth  and  not  to  attempt  to 


Ar 

i 

\ 

/ 

*  'oH^^--. 

J. 

4 

\ 

/    7  c/<  vi/  &  &..£>,' 

1  <^*<c-. 

Fig.  293. — Method  of  holding  back  Head  to  protect  Perineum. 

bear  down,  the  anaesthesia  is  deepened.  At  the  same  time  two  fingers 
are  applied  just  behind  the  anus,  and  forward  and  upward  pressure  is 
made  upon  the  brow  through  the  perinseum. 

The  student  is  warned  from  attempting  to  protect  the  perinaBum  by 
any  method  which  aims  at  stripping  it  back  over  the  presenting  part. 
Such  a  procedure  is  useless,  even  if  carried  out  successfully,  and  not  infre- 
quently, while  it  is  being  attempted,  the  head  will  suddenly  shoot  past 
the  hand  and  cause  a  more  or  less  severe  laceration.  The  same  may 
be  said  of  the  introduction  of  the  finger  into  the  anus,  for  the  purpose  of 
drawing  the  perinaaum  up  over  the  head,  as  suggested  by  Dr.  Gooclell.  In 
fact,  all  such  procedures  are  not  only  of  questionable  utility,  so  far  as 
the  protection  of  the  perinasum  is  concerned,  but  are  dangerous  in  that 
they  contaminate  the  hand  and  throw  it  out  of  function  in  case  an 
emergency  should  arise  which  calls  for  its  prompt  introduction  into  the 
genital  tract. 

Many  obstetricians  introduce  one  or  two  fingers  into  the  vagina  as 
soon  as  the  head  appears  at  the  vulval  opening,  so  that  it  may  not  sur- 


DELIVERY   OF  THE  SHOULDERS 


L's., 


prise  theiu  by  a  sudden  advance.  Such  a  practice  is  extremely  reprehen- 
sible, as  it  markedly  increases  the  possibility  of  contamination  and  in- 
fect ion. 

.Many  authorities,  when  rupture  of  the  perinaeum  seems  imminent,  ad- 
vise the  performance  of  episiotomy.  Jn  this  operation  a  strong  pair  of 
scissors  is  introduced  between  the  head  and  the  perinaeum,  and  an  oblique 
incision  made  downward  and  backward  on  either  side  between  the  anus 
and  the  tuber  ischii.  The  operation  is  practised  in  the  belief  that  the 
vulval  opening-,  if  sufficiently  enlarged  by  the  incisions,  will  not  tear  far- 
ther, or  that  in  any  case  the  laceration  will  occur  in  the  continuation  of 
the  incisions,  whose  clean-cut  edges  will  heal  more  readily  than  the  irregu- 
lar spontaneous  tears.  Personally,  I  see  no  advantage  in  the  procedure,  as 
my  experience  is  that  ordinary  perineal  tears  will  heal  almost  uniformly  if 
properly  sutured  and  cared  for. 

Coils  of  Cord  about  the  Neck. — Immediately  after  the  birth  of  the  head 
the  finger  should  be  passed  to  the  neck  of  the  child  in  order  to  ascertain 

whether  it  is  encircled  by  one  or  more 
coils  of  the  umbilical  cord.  This  com- 
plication occurs  in  about  every  fourth 
case,  and  the  vessels  are  sometimes 
pressed  upon  so  tightly  that  asphyxia- 
tion results.  If  such  a  coil  be  felt,  it 
should  be  drawn  down  between  the  fin- 
gers, aud,  if  loose  enough,  slipped  over 
the  child's  head;  but  if  the  cord  be  too 


Fig.  294. — Traction  to  bring  about 
Descent  of  Anterior  Shoulder 
(Bumm). 

tightly  applied  to  permit  of  this  pro- 
cedure, and  the  head  appears  congested  and 
suffused,  the  former  should  be  seized  and  cut 
between  two  artery  clamps,  and  the  child  imme- 
diately extracted. 

Delivery  of  the  Shoulders. — In  the  majority  of  cases  the 
shoulders  appear  at  the  vulva  just  after  the  occurrence  of  exter- 
nal rotation,  and  are  born  without  difficulty.    Occasionally,  however,  a  delay 
occurs  and  immediate  extraction  may  appear  advisable.    To  accomplish  this 
the  occiput  and  chin  should  be  seized  by  the  two  hands,  and  downward  trac- 
tion made  until  the  anterior  shoulder  appears  under  the  pubic  arch;  next, 


290 


OBSTETRICS 


by  an  upward  movement,  trie  posterior  shoulder  should  be  delivered,  after 
which  the  other  will  usually  drop  from  beneath  the  symphysis. 

The  body  almost  always  follows  the  shoulders  without  difficulty,  but 
in  case  of  prolonged  delay  its  birth  may  be  hastened  by  traction  upon  the 
head,  but  not  by  hooking  the  fingers  in  the  axillae,  since  by  the  latter  pro- 
cedure the  nerves  of  the  arm  may 
be  injured  and  transient  or  perma- 
nent paralysis  result.    Indeed,  even 
the  former  method  of  extraction  is 
not  devoid  of  danger,  for  occasion- 
ally the  oblique  traction  employed 
may  cause  excessive  stretching  of 
the  brachial  plexus,  with  subsequent 
paralysis. 

Tying    the    Cord. — Immediately 


/ 


Fig.  295.- 


-Delivery  of  Posterior  Shoulder 
(Bumm). 


after  its  birth  the  child  usually 
makes  an  inspiratory  movement  and 
then  begins  to  cry.  Under  such  cir- 
cumstances it  should  be  placed  be- 
tween the  patient's  legs  in  such  a 
manner  as  to  leave  the  cord  lax  and 
thus  avoid  traction  upon  it.  If,  how- 
ever, the  child  does  not  begin  to 
breathe  immediately,  the  cord  should 
be  seized  and  cut  between  two  artery  clamps,  and  efforts  at  resuscitation 
commenced  at  once. 

Normally,  the  cord  should  not  be  ligated  until  it  has  ceased  to  pul- 
sate. In  securing  it,  a  ligature  of  sterilized  bobbin  should  be  applied  2 
centimetres  from  the  abdomen  of  the  child  and  tightly  tied;  a  second  liga- 
ture is  placed  several  centimetres  above  the  first,  and  the  cord  cut  be- 
tween the  two.  Usually  ligation  of  the  maternal  end  merely  serves  to  avoid 
soiling  the  bedclothes  by  blood  escaping  from  it;  but  in  twin  pregnancies 
double  ligation  is  essential,  for  when  the  two  foetuses  are  derived  from  a 
single  ovum  there  is  marked  anastomosis  in  the  placental  circulation,  so 
that  the  second  child,  while  still  in  the  uterus,  may  bleed  to  death  from  the 
maternal  end  of  the  cord  of  the  first. 


ANESTHESIA  29  J 

The  question  as  to  the  proper  bime  for  lying  the  cord  has  given  rise  to 
a  great  deal  of  discussion.  Formerly  it  was  the  custom  to  Ligate  it  imme- 
diately after  the  birth  of  the  child;  bul  Budin  showed  thai  92  cubic  centi- 
metres more  blood  escaped  from  the  maternal  end  of  the  cord  after  earh 
than  after  late  ligation,  thus  Indicating  thai  thai  amount  was  lost  to  the 
fietus  by  early,  and  saved  for  it  by  late  ligation.  Schucking  also  demon- 
strated the  same  I'aet  by  weighing  the  child  just  alter  birth  and  again 
after  the  cord  had  ceased  to  pulsate,  and  was  able  to  demonstrate  a  corre- 
sponding  increase  in  weight  in  the  latter  case.  Budin  believed  that  this 
amount  of  blood  was  drawn  into  the  circulatory  system  of  the  foetus  by 
thoracic  aspiration,  while  Schucking  held  that  it  was  driven  into  it  as  a 
result  of  the  compression  of  the  placenta  by  the  contracting  uterus.  Hof- 
meier,  Zweifel,  and  Eibemont  have  also  shown  that  the  initial  loss  of 
weight  in  the  first  few  days  after  birth  is  usually  less  after  late  than  after 
early  ligation. 

I  have  always  practised  late  ligation  of  the  cord  and  have  seen  no  in- 
jurious effects  following  it,  and  therefore  recommend  its  employment  un- 
less some  emergency  arises  which  calls  for  earlier  interference. 

After  ligation  of  the  cord,  the  child  should  be  wrapped  in  a  piece  of 
flannel  or  blanket  prepared  for  the  purpose,  and  laid  in  a  safe  place  until 
the  placenta  is  born  and  the  mother  has  been  cleaned  up  and  made  com- 
fortable. 

Anaesthesia. — We  are  indebted  to  Sir  James  Y.  Simpson,  the  discoverer 
of  chloroform,  for  the  introduction  of  anaesthesia  into  obstetrical  practice. 
He  employed  ether  for  this  purpose  in  the  year  1847,  and  replaced  it  by 
chloroform  after  the  discovery  of  the  latter  drug.  Every  one  agrees  as  to 
the  marked  benefits  derived  from  anaesthesia  when  operative  procedures 
are  to  be  undertaken,  but  there  is  still  considerable  difference  of  opinion 
as  to  the  advisability  of  its  routine  employment  in  normal  labour. 

The  most  popular  anaesthetics  are  ether  and  chloroform,  and  when 
obstetrical  operations  are  to  be  performed  it  makes  very  little  difference 
which  is  employed,  as  it  is  well  known  that  the  clangers  incident  to  chloro- 
form are  markedly  reduced  at  the  time  of  labour,  and  that  only  a  very  few 
deaths  have  followed  its  use  under  such  circumstances.  Exactly  why  the 
parturient  woman  should  enjoy  this  immunity  is  a  question  which  has  not 
yet  been  definitely  settled,  but  it  is  nevertheless  a  fact  which  has  been 
established  beyond  peradventure. 

On  the  other  hand,  chloroform  is  far  preferable  in  normal  labour,  for 
by  its  use  obstetrical  anaesthesia  can  be  rapidly  and  safely  produced; 
whereas  ether,  owing  to  its  slower  action,  does  not  lend  itself  so  readily 
to  this  method  of  employment.  As  the  result  of  my  experience,  I  believe 
that  chloroform,  when  properly  administered,  is  practically  devoid  of 
danger  in  such  cases,  and  should  be  used  whenever  there  is  time  for  its 
administration.  Of  course  it  is  contra-indicated  when  the  patient  has  re- 
ligious objections  to  its  use,  as  well  as  in  those  cases  in  which  labour  is 
almost  painless. 

The  choice  of  the  time  for  its  administration,  however,  is  of  great 
importance,  nor  should  it  be  used  before  the  latter  part  of  the  second 
20 


292  OBSTETRICS 

stage,  when  the  head  becomes  visible  at  the  vulva,  or  at  least  until  the  peri- 
naeum  begins  to  bulge.  A  few  drops  of  chloroform  should  then  be  poured 
upon  the  inhaler,  and  with  the  beginning  of  a  pain  the  patient  should  be 
instructed  to  breathe  in  the  fames  vigorously;  but  as  soon  as  the  contraction 
has  ceased  the  inhaler  should  be  removed,  to  be  used  again  when  the  patient 
makes  a  sign  that  she  feels  the  first  indication  that  another  is  beginning. 
When  the  distention  of  the  vulva  is  at  its  maximum,  obstetrical  anaesthesia 
is  not  sufficient  to  abolish  the  pain,  and  it  is  my  practice,  as  the  head 
emerges,  to  render  my  patient  completely  unconscious  for  the  moment  by 
increasing  the  dose  of  the  drug. 

By  this  procedure  the  woman  is  saved  an  immense  amount  of  unneces- 
sary pain,  and  at  the  same  time  the  danger  of  perineal  laceration  is  dimin- 
ished. For,  if  the  suffering  is  minimized,  and  done  away  with  entirely  at 
the  critical  moment,  the  patient  will  lie  still  instead  of  tossing  in  her  bed, 
and  there  will  not  be  the  same  danger  of  the  head  being  suddenly  expelled 
at  the  acme  of  a  contraction,  while  the  physician  is  employing  his  energies 
in  persuading  the  patient  to  keep  quiet,  or  may  even  be  forcing  her  legs 
apart  so  that  he  may  be  able  to  protect  the  perinaeum.  The  amount  of 
chloroform  required  for  this  purpose  is  very  small,  and  rarely  exceeds  2  or 
3  drams. 

For  various  reasons,  the  administration  of  chloroform  should  be  de- 
ferred as  long  as  possible  in  the  second  and  never  resorted  to  in  the  first 
stage,  unless  exceptional  indications  call  for  its  employment.  Leaving  out 
of  consideration  its  possible  influence  upon  the  efficiency  of  the  uterine 
contractions,  it  is  only  natural  that  as  soon  as  the  patient  has  experienced 
the  soothing  effects  of  the  drug  she  is  extremely  loath  to  do  without  it, 
and,  once  having  begun,  the  physician  may  find  himself  forced  to  continue 
its  administration  for  a  considerable  length  of  time,  unless  he  possesses 
more  fortitude  than  is  generally  the  case. 

Against  the  employment  of  anaesthetics  in  labour  it  has  been  urged 
that  they  diminish  the  force  of  the  uterine  contractions.  This  statement 
is  partially  correct,  for  when  administered  for  any  great  length  of  time 
they  undoubtedly  lead  to  a  shortening  of  the  uterine  contractions  and  to 
a  prolongation  of  the  interval  between  them,  as  was  clearly  demonstrated 
by  the  experiments  of  Donhoff  and  Hensen.  On  the  other  hand,  when 
exhibited  only  at  the  proper  time  and  in  no  excessive  amount,  this  ob- 
jection does  not  hold  good,  and  in  many  instances  small  doses  appear  to 
stimulate  the  uterine  contractions,  and  by  diminishing  the  sensation  of 
pain  enable  the  patient  to  bring  her  abdominal  muscles  into  full  play, 
which  she  previously  may  have  been  unwilling  to  do,  and  thus  hasten  the 
completion  of  labour. 

Again,  it  has  been  taught  that  anaesthesia  predisposes  to  relaxation  of 
the  uterus  after  the  expulsion  of  the  placenta,  and  thus  increases  the 
danger  of  post-partum  haemorrhage.  So  far  as  my  own  experience  goes, 
such  sequelae  are  not  likely  to  occur  provided  the  drug  has  been  properly 
administered.  At  the  same  time  it  must  be  admitted  that  its  prolonged 
administration  certainly  tends  towards  uterine  inertia,  and  is  not  without 
a  deleterious  influence  upon  the  child. 


COCAINE    ANESTHESIA  293 

In  exceptional  cases  chloroform,  while  diminishing  the  pain,  appears 
to  excite  the  patient.  Under  such  conditions  it  should  not  be  employed 
unless  complete  anaesthesia  is  necessary.  It  should  neve!'  be  used  in  the 
first  stage  of  prolonged  labours  in  the  hope  of  hastening  the  dilatation  of 
the  cervix,  as  this  object  is  better  attained  by  the  proper  administration 
of  chloral  or  morphia. 

Ordinarily  the  patient  is  allowed  to  come  from  under  the  influence 
of  the  anaesthetic  as  soon  as  the  child  is  born,  as  its  exhibition  is  not 
necessary  in  the  third  stage  of  labour,  except  when  the  placenta  is  to  be 
removed  manually  or  an  extensive  perineal  laceration  is  to  be  repaired. 
Moreover,  it  should  be  remembered  that  after  the  birth  of  the  child  the 
patient  does  not  appear  to  enjoy  the  same  immunity  as  when  in  active 
Labour. 

Cocaine  Ancesihesia. — Following  the  rehabilitation  by  Bier  of  the  sub- 
arachnoidal injection  of  cocaine  for  the  production  of  anaesthesia  of  the 
lower  portion  of  the  body,  and  its  popularization  by  the  work  of  Tuffier,  it 
was  but  natural  that  its  efficiency  should  be  tested  upon  the  parturient 
woman. 

The  first  publication  concerning  its  employment  at  the  time  of  labour 
was  made  in  August,  1900,  by  Kreis,  who  reported  the  results  obtained  in 
6  cases  in  Bumm's  clinic  in  Bale.  It  would  appear,  however,  that  Doleris 
was  working  simultaneously  upon  the  same  lines.  Since  then  a  number  of 
observers,  notably  Marx,  Stone,  Demelin,  and  Doleris  and  Malartic  have 
reported  series  of  cases  treated  in  this  manner.  From  their  reports,  as  well 
as  from  observations  made  in  my  clinic,  there  is  no  doubt  that,  most  striking 
results  are  obtained  in  a  certain  proportion  of  cases. 

In  favourable  cases,  the  patient  being  in  the  second  stage  of  labour, 
the  injection  into  the  lumbar  portion  of  the  vertebral  canal  of  10  to  15__ 
minims  of  a  1-pex^cant  solution  of  cocaine  (-^g— ^  grain)  is  followed  with- 
in a  few  minutes  by  complete  abolition  of  painful  sensations.  At  the  same 
time,  the  patient  continues  to  make  visible  expulsive  efforts  with  great 
regularity  and  ofttimes  with  increased  frequency,  so  that  if  the  effects  of 
the  drug  do  not  wear  off  too  rapidly,  the  child  may  be  expelled  without 
pain  and  almost  without  the  knowledge  of  the  patient.  Likewise,  various 
operative  procedures,  such  as  maima]  dilatation  of  the  cervix,  version^ _or_ 
forceps,  may  be  painlessly  performed. 

Notwithstanding  these  very  wonderful  results,  I  do  not  hesitate  to  ad- 
vise strongly  against  the  employment  of  the  method  in  obstetrical  practice, 
and  therefore  shall  not  enter  into  the  details  of  the  technique  of  making  the 
injection.  In  the  first  place,  the  results  are  not  always  uniform,  a  certain 
number  of  patients  appearing  to  be  absolutely  refractory  to  the  influence 
of  the  drug  when  administered  in  doses  consistent  with  safety.  Again, 
its  effects  are  sometimes  very  transient  and  fade  away  just  when  most 
needed.  More  serious,  however,  are  the  after-effects,  the  majority  of  pa- 
tients suffering  severely  from  headache  -and  .nausea^  and  frequently  from  an 
alarming  but  transient  elevation  of  temperature.  In  view  of  their  compara- 
tively short  duration,  these  symptoms  are  usually  regarded  as  a  manifesta- 
tion of  intoxication  rather  than  of  infection. 


294  OBSTETRICS 

The  most  serious  objection  to  the  method  is  the  fact  that  Hahn,  in  1901, 
reported  8  deaths  in  1,708  cases  in  which  its  use  has  been  recorded  in  the 
literature  (1-200).  ISTo  doubt,  in  several  instances  the  fatal  issue  could  not 
be  fairly  attributed  to  the  method,  but  in  several  others  the  autopsy  showed 
lesions  of  the  spinal  or  cerebral  meninges  which  could  be  due  only  to 
infection. 

In  view,  therefore,  of  its  various  shortcomings  and  dangers,  I  see  no 
reason  to  recommend  the  employment  of  spinal  anaesthesia  in  obstetrics, 
being  convinced  that  more  uniform  and  satisfactory  results  may  be  obtained 
by  the  proper  administration  of  chloroform  with  far  greater  safety  to  the 
patient.  Moreover,  were  spinal  anaesthesia  to  come  into  more  extended 
use,  under  the  adverse  conditions  frequently  encountered  in  private  prac- 
tice, I  feel  sure  that  many  women  would  perish  from  meningitis,  the  result 
of  the  imperfect  application  of  the  rules  of  aseptic  technique. 

Hypnotism. — Numerous  observers,  among  whom  may  be  mentioned 
Leichstein,  Cocke,  and  others,  have  reported  instances  in  which  labour 
was  painlessly  conducted  under  the  influence  of  hypnotism.  Personally  I 
have  seen  it  employed  successfully  in  only  a  single  instance.  As  a  rule,  its 
field  of  usefulness  in  obstetrics  is  very  limited,  for  the  reason  that  the 
patient  must  be  a  susceptible  subject,  and  one  who  has  already  been  hyp- 
notized on  previous  occasions. 

The  Use  of  Ergot. — Many  authorities  recommend  the  administration  of 
a  dram  of  fluid  extract  of  ergot  by  the  mouth  immediately  after  the 
expulsion  of  the  placenta,  as  a  prophylactic  measure  against  post-partum 
haemorrhage.  This  is  usually  unnecessary,  as  the  drug  is  called  for  only 
in  those  cases  in  which  the  uterus  remains  soft  and  flabby,  instead  of 
forming  a  hard  tumour  beneath  the  umbilicus.  Personally,  I  always  pre- 
fer to  administer  it  hypodermically,  and  have  found  the  ergotol  prepared 
by  Sharp  and  Dohme  much  better  than  the  officinal  fluid  extract,  inasmuch 
as  it  is  less  likely  to  produce  an  abscess  at  the  point  of  injection.  In- 
stead of  being  inserted  just  under  and  parallel  to  the  skin,  the  needle  is 
plunged  deeply  into  the  muscle  of  the  thigh,  and  from  30_jx>  40  minims 
are  injected,  the  dose  being  repeated  if  necessary.  It  should  be  remem- 
bered that  such  injections  usually  give  rise  to  a  slight  but  painful  indura- 
tion, which  persists  for  several  days,  but  only  exceptionally  eventuates  in 
abscess  formation. 

I  must  insist  once  more  that  this  is  the  only  time  at  which  ergot 
should  be  employed  in  labour,  as  its  administration  before  the  completion 
of  the  third  stage  ha:  led  to  untold  harm.  Formerly,  even  well-trained 
physicians  used  it  in  large  quantities  during  the  second  stage  to  stimulate 
uterine  contractions,  but  at  the  present  time  it  ap .  so  employed  only  by 
ignorant  midwives.  The  danger  lies  in  the  fact  that  the  premature  use 
of  the  drug  readily  leads  to  tetanic  contractions  of  the  uterus,  which  in  the 
presence  of  any  marked  disproportion  between  the  size  of  the  child  and 
pelvis  are  likely  to  bring  about  rupture  of  the  uterus  and  the  death  of  the 
patient.  Moreover,  its  administration  in  the  third  stage  of  labour,  before 
the  expulsion  of  the  placenta,  cannot  be  too  strongly  deprecated,  as  the 
resulting  tetanic  contraction  tends  rather  to  produce  a  further  retention 


REPAIR   OF  THE   LACERATED   PERINiEUM 


295 


«»!'  the  organ,  so  thai  not  infrequently  its  manual  removal  becomes  im- 
perative. 

Conduct  of  the  Third  Stage  of  Labour. — This  subject  has  already  been 
considered  in  the  preceding  chapter. 

Ii'i' pair  of-  the  Lacerated  Perincsum. — Strictly  speaking,  this  subject 
should  be  deferred  until  the  obstetrical  operations  are  dealt  with;  but  as 
perinea]  (cars  are  of  such  frequent  occurrence,  and  as  they  are  best  re- 
paired in  the  interval  between  the  birth  of  the  child  and  the  expulsion 
of  tlic  placenta,  the  proper  method  of  procedure  will  be  considered  at 
this  t ime. 

For  convenience  in  description,  perineal  tears  are  divided  into  three 
groups,  those  of  the  first,  second,  and  third  degrees.     To  the  first  belong 


,. 


Fig.  296. — Superficial  Perineal  Tear. 


Fig.  297. — Deep  Perineal  Tear. 


those  which  involve  simply  the  fourchette  and  anterior  margin  of  the 
perinaeum,  giving  rise  to  a  small,  triangular  wounded  surface  which  is 
rarely  more  than  1.5  centimetre  deep. 

In  the  second,  the  laceration  extends  through  a  greater  or  lesser  por- 
tion of  the  perineal  body,  and  not  infrequently  exposes  the  sphincter  ani 
muscle.  Usually  its  course  does  not  quite  follow  the  median  line,  but  is 
directed  obliquely  downward  and  outward  from  the  posterior  margin  of  the 
vulva.  In  many  of  these  cases  there  are  also  lesions  of  the  vagina.  The  lat- 
ter usually  involve  the  sulcus  on  the  same  side  as  the  perineal  tear,  but  fre- 
quently that  on  the  other  side  as  well,  so  that  a  triangular  portion  of  the 
vaginal  mucosa,  which  represents  the  inferior  extremity  of  the  posterior 
column,  may  become  separated  from  the  rest  of  the  canal. 


296 


OBSTETRICS 


In  the  third  degree,  the  tear  extends  completely  through  the  perineal 
body  and  the  sphincter  ani  muscle,  and  for  a  certain  distance  up  the  an- 
terior wall  of  the  rectum,  tnus  giving  rise  to  a  cloaca,  into  which  both 

vagina  and  rectum  open.  These  are 
designated  as  complete,  in  contradis- 
tinction to  those  of  the  first  and  sec- 
ond degrees — the  incomplete  tears — 
in  which  the  rectum  is  not  involved. 
Incomplete  tears  are  encountered  very 
often,  even  in  the  practice  of  the  most 
competent  obstetricians,  no  matter 
what  precautions  may  be  taken  to  pre- 
vent them;  but  the  frequent  occur- 
rence of  the  complete  varieties  indi- 
cates that  the  method  employed  for 
protecting  the  perinseum  has  been  at 
fault  in  spontaneous,  or  that  the  ex- 
traction has  been  too  forcible  or  hasty 
in  operative  deliveries. 

In  tears  of  the  first  degree,  the 
mucous  membrane  of  the  fourchette 
and  the  skin  covering  the  upper  por- 
tion of  the  perinseum  and  the  sub- 
cutaneous tissue  are  implicated;  in 
those  of  the  second  degree,  the  skin 
surface  of  the  perinseum,  the  various 
perineal  muscles,  particularly  the  con- 
strictor vagina?  and  transversus  perinei,  are  torn  through,  and  the  wide 
gaping  wound  is  due  in  great  part  to  the  laceration  of  the  last-named 
muscles.  When  the  tear  extends  up  the  vagina,  certain  fibres  of  the 
levator  ani  muscle  are  likewise  involved;  while  in  lacerations  of  the  third 
degree,  the  sphincter  ani  muscle  and  the  anterior  surface  of  the  rectum  are 
implicated  in  addition  to  the  structures  above  named. 

As  has  been  said,  the  perineal  tear  commences,  as  a  rule,  at  the  four- 
chette and  extends  obliquely  downward  and  outward  from  it.  But  in  the 
very  rare  cases  in  which  the  vulval  outlet  looks  markedly  upward,  or  in 
which  the  perinseum  is  extremely  resistant  and  the  mechanism  of  expul- 
sion faulty,  the  laceration  may  begin  in  the  central  portion  of  the  peri- 
nseum, and  the  head  appear  in  an  opening  which  is  surrounded  on  all  sides 
by  skin.  This  is  known  as  a  central  tear,  and  is  of  extremely  infrequent 
occurrence.  Ordinarily,  as  the  head  is  forced  down  still  farther,  the  tear 
extends  towards  the  fourchette  or  towards  the  anus,  or  even  in  both  direc- 
tions, and  thus  gives  rise  to  a  deep,  incomplete,  or  complete  laceration 
as  the  case  may  be. 

In  not  a  few  cases,  where  the  vaginal  ojDening  is  very  resistant,  ^nd 
when  the  head  has  remained  a  long  time  upon  the  pelvic  floor,  even 
although  there  may  be  no  external  wound  or  appreciable  lesion  of  the 
vagina,  there  may  nevertheless  have  occurred  a  submucous  tear  or  separa- 


Fig.  298. — Complete  Perineal  Tear. 


REPAIR   OK   THE    LACERATED    I'KUIX  Jll'.M 


297 


tion  of  certain  fibres  of  the  Levator  ani  muscle,  which  will  later  give  rise 
to  a  marked  relaxation  of  I  lie  vaginal  outlet.  Not  infrequently  the  con- 
dition, although  unrecognized  al  t  lie  I  Line,  later  gives  rise  to  such  aggravated 
symptoms  as  to  call  for  operation  years  after  the  birth  of  the  child. 

No  matter  what  the  degree,  the  immediate  closure  of  perineal  lacera- 
tions by  suture  is  urgently  indicated.  Even  slight  tears  through  the  four- 
chette  are  better  repaired  than  left  alone,  for  if  not  united  by  suture  they 
arc  often  extremely  painful,  and  furnish  an  excellent  nidus  for  infection 
in  case  the  nurse  is  lax  in  her  care  of  the  patient.  In  more  extensive 
tears  immediate  repair  is  always  necessary,  unless  the  condition  of  the  pa- 
tient be  so  serious  as  to  contra-indicate  further  operative  procedures. 

For  these  operations,  the  patient  should  be  brought  to  the  edge  of  the 
bed  and  placed  in  the  lithotomy  position, 
and  the  sutures  introduced  while  waiting 
for  the  expulsion  of  the  placenta.  They 
should  not  be  tied  until  the  completion  of 
the  third  stage,  as  the  distention  of  the 
vulva  by  the  placenta  may  subject  the  re- 
paired wound  to  undue  strain.  By  intro- 
ducing the  sutures  during  this  period  a  good 
deal  of  time  is  saved,  and  the  temptation 
to  hasty  expression  of  the  placenta  is  diminished,  since  the  physician  has 
plenty  to  do  while  waiting  for  the  fundus  to  rise  up. 

The  mode  of  repairing  the  wounded  perinseum  differs  according  as  the 
tear  extends  only  through  the  perineal  body  or  is  complicated  by  lacera- 
tions of  the  vagina  or  rectum.  In  the  first  case,  the  wound  should  be 
closed  by  deep  sutures  of  silkworm  gut,  which  are  introduced  at  least  0.5 
centimetre  from  one  margin  and  carried  well  down  under  its  base,  being 
then  brought  out  through  the  skin  surface  on  the  opposite  side.  It  is 
important  that  the  sutures  should  be  inserted  and  emerge  at  a  consider- 
able distance  from  the  edges  of  the  wound,  for,  owing  to  the  marked 
oedema  which  frequently  follows  their  introduction,  they  are  very  prone 
to  tear  through  unless  this  precaution  be  taken.  They  should  be  placed  at 
intervals  of  about  1  centimetre,  and  if  accurate  approximation  is  not 
secured  in  this  way  superficial  sutures  should  be  employed  between  them. 
Large  curved  needles,  which  can  make  the  entire  sweep  at  a  single  move- 


Fig.  299. — Needle  for  Repairing 
Perineal  Tears. 


Fig.  300. — Xeedle  Holder 


ment,  should  be  used,  as  they  render  much  better  service  than  small 
needles  which  require  several  bites.  The  sutures  should  be  tied  very  loose- 
ly from  below  upward,  and  not  cut  off  short,  their  long  ends  being  twisted 
together  into  a  cord  and  brought  together  into  a  loose  knot,  so  as  not  to 
irritate  the  patient. 


298 


OBSTETRICS 


As  a  suture  material,  silkworm  gut  is  preferable  to  silver  wire,  since  it 
can  be  more  readily  handled.  Silk  sutures  are  objectionable,  as  they 
readily  become  impregnated  with  the  lochial  secretion  and  are  more  likely 
to  favour  infection  of  the  wound.  Ordinary  catgut  is  not  satisfactory  for 
deep  sutures,  as  it  is  too  rapidly  absorbed,  owing  to  the  fact  that  the  ex- 
posed portions  are  kept  moist  by  the  lochia.  It  is  very  useful,  however, 
for  superficial  sutures,  which  are  only  required  to  remain  for  a  short  time. 

When  the  perineal  tear  is  complicated  by  laceration  of  the  vagina,  the 
edges  of  the  latter  should  be  brought  together  by  deep  silkworm  and 
superficial  catgut  sutures,  just  as  in  Emmet's  relaxed  outlet  operation, 
after  which  the  perineal  wound  should  be  repaired  in  the  usual  manner. 


Fig.  301. — Kepair    of    Perineal    Tear 
extending  up  the  vagina. 


Fig.  302. — Same,  Sutures  Tied. 


In  complete  tears,  attention  should  first  be  given  to  the  wounded 
rectum  and  its  ruptured  mucosa  united  by  fine  silk  sutures,  which  are 
knotted  into  the  rectum,  the  ends  being  allowed  to  protrude  from  the 
anus.  When  the  rectum  has  been  repaired,  the  ends  of  the  sphincter  ani 
should  be  isolated  and  firmly  sutured  by  catgut  or  fine  silk  sutures,  after 
which  the  vaginal  and  perineal  tears  should  be  dealt  with  in  the  manner 
indicated  above. 

The  after-treatment  of  all  degrees  of  tears  is  comparatively  simple,  and 
consists  in  keeping  the  wound  clean  and  covered  by  sterile  dressings. 
Whenever  the  latter  are  changed,  the  wounded  surface  should  be  washed 
with  a  l-to-5,000  bichloride  solution  for  a  few  days,  and  later  with  one 
of  boric  acid.    The  continuous  use  of  antiseptic  powders,  such  as  iodoform 


REIWIIJ   OF  THE   LACERATED    PERINEUM  299 

or  boric  acid,  is  not  indicated,  as  the  wounds  heal  equally  well  without 
them.  Nor  is  there  any  necessity  for  binding  the  legs  together,  unless 
the  patienl  is  very  unruly  and  refuses  to  keep  still.  Catheterization 
may  also  In-  dispensed  with,  excepl  in  cases  of  retention,  as  the  How  of 
urine  over  the  wound  does  no  harm,  provided  it  is  followed  by  proper 
cleansing.  Generally  speaking,  the  external  sutures  should  be  removed  on 
the  tenth  day.  and  the  vaginal  stitches  a  few  days  later.  In  tears  of  the 
first  and  second  degrees  the  bowels  should  be  moved  daily,  but  in  com- 
plete Lacerations  it  is  advisable  to  prevent  an  action  for  the  first  two  or  three 
days,  after  which  a  large  high  enema  of  sweet  oil  should  he  given,  followed 
by  calomel  or  castor-oil  by  the  mouth. 

The  results  following  these  operations  are  usually  very  satisfactory, 
and  when  the  parts  have  been  correctly  approximated,  primary  union  is 
the  rule,  provided  the  sutures  have  been  introduced  far  enough  from  the 
margins  of  the  wound  and  not  tied  too  tightly.  This  is  a  point  to  which 
too  much  attention  can  hardly  be  paid,  for  too  often  there  is  a  tendencv  to 
attempt  to  make  a  neat-looking  operation  by  introducing  the  sutures  close 
to  the  margins  of  the  wound  and  tying  them  snugly.  As  a  result  of  this 
short-sighted  policy,  however,  owing  to  the  oedema  which  usually  follow-. 
the-  majority  of  the  stitches  cut  through  and  become  useless,  so  that  union 
by  primary  intention  becomes  impossible.  On  the  other  hand,  when  less 
attention  is  paid  to  the  first  appearance  of  the  wound,  the  sutures  being 
introduced  far  from  its  margins  and  tied  somewhat  loosely,  excellent  re- 
sults almost  always  follow. 

Unfortunately,  operations  for  complete  tears  are  by  no  means  so  satis- 
factory, and  as  a  general  rule  not  more  than  one  half  of  the  cases  heal 
by  first  intention.  In  the  cases  of  complete  or  partial  failure,  a  secondary 
operation  is  indicated  before  the  patient  is  discharged  from  treatment. 

LITERATURE 

Balaxdix.     Ueber  den  Mechanismus  der  Dammrisse  und  der  verschiedenen  Dammschutz- 

verfahren.     Klinisehe  Yortrage.  1883.  Heft  I,  St.  Petersburg,  95-127. 
Bier.     Versuche  iiber  Cocainisirung  des  Riickenmarkes.     Deutsche  Zeitschr.  f.  Chirurgie, 

1899,  li,  361. 
Budix.     A  quel  moment  doit-on  operer  la  ligature  du   cordon  ombilical  '!     Le  Progres 

Medical.  1875,  decembre :  1876.  Janvier.     (Obstetrique  et  Gynecologie,  1886,  1-35.  | 
Demelix.     De  la  cocaine  en  obstetrique.     L'Obstetrique.  1901.  vi.  122-130. 
Doleris  et  Malartic.    Analgesie  obstetricale  par  injections  de  cocaine.    Comptes  rendus 

de  la  soc.  d'obst.,  de  gyn.  et  de  paed.  de  Paris,  1900.  ii,  279-289. 
Doxhoff.     Leber  die  Einwirkung  des  Chloroforms  auf  den  normalen  Geburtsverlauf.  etc. 

Archiv  f.  Gyn..  1892.  xlii.  305-32S. 
Furbrixger.     Lntersuehungen  und  Vorschriften  iiber  die  Desinfection  der  Hande  des 

Arztes.   nebst    Bemerkunsren     iiber    den    bakteriologischen    Character   des    Xagel- 

schmutzes.     Wiesbaden.  1888. 
Giffard.     Cases  in  Midwifery.     London.  1734.  396-398. 
Goodell.     A  Critical  Inquiry  into  the  Management  of  the  Perinaeum  during  Labour. 

Amer.  Jour.  Med.  Sciences.  1871.  lxi.  53-79. 
BTaegler.     Handereinigunir.  Ilandedesinfection  und  Handeschutz.     Basel.  1900. 
Hahx.     Leber  subarachnoideale  Cocaininjectionen  nach  Bier.     Centralbl.  f.  d.  Grenzge- 

biete  der  Med.  u.  Chirurgie.  1901.  iv.  304-317  und  340-354. 


300  OBSTETRICS 

Hensbn.     Ueber  den  Einfluss  des  Morphiuins  und  des  Aethers  auf  die  Wehenthatigkeit 

des  Uterus.     Arehiv  f.  Gyn.,  1898,  lv,  129-177. 
Hofjieier.     Der  Zeitpuukt  der  Abnabelung  in  seinem  Einfluss  auf  die  ersten  Lebenstage 

des  Kindes.     Zeitschr.  f.  Geb.  u.  Gyn.,  1879,  iv,  114-132. 
Kelly.     Hand  Disinfection.     Amer.  Jour.  Obst,  1891,  xxiv,  1414-1419. 
Kreis.     Ueber  Medullarnarkose  bei  Gebarenden.     Centralbl.  f.  Gyn.,  1900,  724-729. 
Kroxig.     Versuche  iiber  Spiritusdesinfeetion  der  Hande.     Centralbl.  f.  Gyn.,  1894,  1346- 

1353. 
Marx.     Analgesia  in  Obstetrics  produced  by  Medullary  Injection  of  Cocaine.     Phila. 

Med.  Jour.,  1900,  vi,  857-859. 
Olshausex.     Ueber  Daminverletzung  und  Dammschutz.     Volkmann's  Sammlung  klin. 

Vortrage,  1872,  Xr.  44. 
Ribemoxt.     Recherches  sur  la  tension  du  sang  dans  les  vaisseaux  du  foetus  et  du  nou- 

veau-ne.     Archives  de  Tocologie,  octobre,  1897. 
Ritgex.     Ueber  ein  Dammschutzverfahren.     Monatsschr.  f.  Geburtsk.,  1855,  vi,  321-347. 
Schroeder.     Lehrbuch  der  Geburtshiilfe,  VII.  Aufl.,  681. 
Schuckixg.     Zur  Physiologie  der  Xachgeburtsperiode.     Berlin,  klin.  Wochenschr.,  1877, 

Xr.  182. 
Simpson.     On  the  Employment  of  the  Inhalation  of  Sulphuric  Ether  in  the  Practice  of 

Midwifery.     Monthly  Jour,  of  Med.  Sciences,  1847,  728. 
Anaesthesia.     Philadelphia,  1849,  248. 
Stone.     Cocainization  of  the  Spinal  Cord  by  Means  of  Lumbar  Puncture  during  Labour. 

Amer.  Jour.  Obstet.,  1901,  xliii,  145-154. 
Tuffier.     L'anesthesie  medullaire  en  gynecologie.     Revue  de  gyn.  et  de  chir.  abd.,  1900, 

iv,  683-692. 
Williams,  J.  Whitridge.     The  Cause  of  the  Conflicting  Statements  concerning  the  Bac- 
terial Contents  of  the  Vaginal  Secretion  of  the  Pregnant   Woman.      Amer.  Jour. 

Obst.,  1898,  xxxviii,  807-817. 
Zweifel.     Wann  sollen  die  Xeugeborenen  abgenabelt  werdeu?    Centralbl.  f.  Gyn.,  1878, 

1-3. 


CHAPTER   XVI 


THE  PUERPERIUM 


The  puerperium  or  puerperal  state  comprises  the  five  or  six  weeks  fol- 
lowing labour  which  are  required  for  the  return  of  the  generative  tract  to 
its  normal  condition.  Although  the  changes  occurring  during  this  period 
are  considered  as  physiological,  they  border  very  closely  upon  the  patho- 
logical, inasmuch  as  under  no  other  circumstances  does  such  marked  and 
rapid  tissue  metabolism  occur  without  a  departure  from  a  condition  of 
health. 

Anatomical  Changes  in  the  Puerperium. — Involution  of  the  Uterus. — 
Immediately  following  the  expulsion  of  the  placenta,  the  contracted  and 
retracted  body  of  the  uterus  forms  a  hard  muscular  tumour,  the  apex  of 
which  lies  about  midway  between  the  umbilicus  and  symphysis,  usual- 
ly 12  centimetres  (4f 
inches)  above  the  lat- 
ter. During  the  next 
few  days  the  uterus  de- 
creases so  rapidly  in 
size  that  by  the  tenth 
day  it  has  descended 
once  more  into  the 
cavity  of  the  true  pel- 
vis, and  can  no  longer 
be  felt  above  the  sym- 
physis. It  reaches  its 
normal  size  by  the  end 
of  five  or  six  weeks. 
Some  idea  of  the  ra- 
pidity with  which  the 
process  goes  on  may 
be  gained  by  recalling 
the  fact  that  the  fresh- 
ly delivered  uterus  weighs  about  1,000  grammes,  one  week  later  500 
grammes,  at  the  end  of  the  second  week  375  grammes,  and  at  the  end  of 
the  puerperium  only  60  grammes. 

This  rapid  decrease  in  size  is  due  to  what  is  designated  as  involution, 
and  is  brought  about  mainly  by  changes  occurring  in  the  muscular  layer. 
On  examining  the  uterus  of  a  woman  dying  immediately  after  labour,  one 

301 


Fig.  303, 


Frozen  Section,  showing  Uterus  iitaiediatelt  After 
Delivery  (Webster). 


302  OBSTETRICS 

is  struck  with  its  markedly  anaemic  appearance  as  compared  with  that  of 
the  pregnant  organ.  This  is  due.,  according  to  "Webster,  to  compression 
of  its  vessels  l>j  the  contracting  and  retracting  muscular  fibres",  and 
represents  the  first  stage  of  its  involution.  At  the  same  time  a  con- 
siderable portion  of  the  tissue  juices  is  expressed  from  it  by  the  same 
mechanism. 

It  was  formerly  believed  that  the  muscle  cells  underwent  fatty  de- 
generation during  the  puerperium,  and  that  large  numbers  of  them  com- 
pletely disappeared.  The  researches  of  Sanger  have  shown,  however,  that 
only  the  excess  of  protoplasm  is  so  removed,  and  that  the  actual  number 
of  individual  cells  is  not  materially  diminished.  In  other  words,  they 
undergo  marked  atrophy,  but  are  not  destroyed.  Sanger  estimated  that 
their  average  length  in  the  full-term  uterus  was  208.7  microns,  as  com- 
pared with  24.4  microns  five  weeks  after  labour. 

As  has  been  said  before,  the  separation  of  the  placenta  and  its  mem- 
branes occurs  in  the  inner  portion  of  the  spongy  layer  of  the  decidua, 
and  accordingly  the  greater  part  ot  tins  layer  remains  ill  the  uterus  after" 
their  expulsion.  It  presents  an  irregular,  jagged  appearance,  and  is  mark- 
edly infiltrated  with  blood,  especially  at  the  placental  site.  As  the  result 
of  hyalin  and  fatty  degeneration,  the  greater  portion  of  this  tissue  is  cast 
off  in  the  lochia,  leaving  behind  only  the  fundi  of  the  glands  of  the  spongy 
layer  and  a  minimal  amount  of  connective  tissue,  from  which  the  new  endo- 
metrium is  regenerated. 

The  processes  concerned  in  its  regeneration  have  been  carefully  studied 
by  Friedlander,  Kundrat  and  Engelmann,  Leopold,  Kronig,  and  others, 
and  it  has  been  definitely  shown  that  the  epithelium  of  the  new  endo- 
metrium results  from  the  proliferation  of  the  epithelial  cells  of  the  fundi 
of  the  glands  of  the  decidua,  whereas  the  connective  tissue  is  derived  from 
the  interglandular  "stroma.  Except  at  the  placental  site,  the  process  is 
ordinarily  completed  b~y~the  end  of  four  to  six  weeks. 

Pels  Leusden  has  recently  advanced  the  view  that  the  syncytial  tissue 
lying  in  the  deeper  portions  of  the  decidua  and  the  upper  layers  of  the 
muscularis  plays  an  important  part  in  the -process,  and  that  the  greater 
portion  of  the  new  epithelium  is  derived  from  it.  This  theory  was  for- 
mulated at  a  time  when  it  was  believed  that  the  syncytium  was  of  ma- 
ternal origin,  but  since  it  has  been  shown  that  it  represents  foetal  ectoderm, 
such  a  view  is  no  longer  tenable. 

Changes  in  the  Uterine  Vessels. — Immediately  after  the  completion  of 
the  third  stage  of  labour,  the  placental  site  is  represented  by  an  irregular, 
nodular,  elevated  area  of  about  the  size  of  the  palm  of  the  hand,  the 
elevations  being  due  to  the  presence  of  thrombosed  vessels.  This  area  de- 
creases rapidly  in  size,  so  that  it  measures  3  or  4  centimetres  in  diameter 
at  the  end  of  the  second  week,  and  only  1  to  2  centimetres  at  the  com- 
pletion of  the  puerperium,  although  it  still  remains  elevated  above  the 
general  surface  of  the  interior  of  the  uterus  and  is  tinged  with  blood  pig- 
ment. Its  original  position  remains  recognisable  for  quite  a  long  period, 
and  even  six  months  after  childbirth  appears  as  a  slightly  elevated  pig- 
mented area. 


ANATOMICAL  CHANGES  IN  THE   PUERPERIUM  303 

In  the  Lasl  month  of  pregnancy  some  of  the  sinuses  al  the  placental 
site  undergo  thrombosis,  bul   the  process   becomes  more  marked   in  the 

latter  jhTtTiiiTi  of  tin1  "sTm^TTTTi I  and  particularly  after  the  completion  of  the 
third  stage  of  labour,  although  many  sinuses  never  become  thrombosed,  but 
are  simply  compressed  by  the  contracting  uterine  muscle.  The  thrombi 
become  organized  by  the  proliferation  of  the  intima  of  the  vessels,  and 
eventually  are  converted  into  typical. connective  tissue. 

As  the  non-pregnant  uterus  requires  a  much  less  abundant  blood 
supply  than  the  pregnant  organ,  it  is  apparent  that  the  lumina  of  its 
various  arteries  must  undergo  a  certain  amount  of  constriction.  This  is 
brought  about  by  a  compensatory  endarteritis,  which  is  not  infrequently 
associated  with  hyalin  changes  in  tne  tunica  media.  The  latter  persist 
for  years,  and  under  the  microscope  offer  a  ready  means  of  differentiating 
between  the  uteri  of  women  who  have  and  of  those  who  have  not  borne 
children. 

Changes  in  the  Cervix,  Vagina,  one]  Vaginal  Outlet. — Immediately  after 
the  completion  of  the  third  stage,  the  cervix  is  represented  by  a  soft, 
muscular  tube,  whose  boundaries  can  be  made  out  only  with  difficultv. 


Fig.  304. — Frozen   Section   just    After    Completion    of    Third    Stage    of    Labour,  showing 

Collapse  of  Lower  Uterine  Segment  and  Cervix  (Benckiser). 

C.E.,  contraction  ring;  O.E.,  external  os;  O.I.,  internal  os. 

The  margins  of  the  external  os  are  soft  and  flabby,  and  are  usually  marked 
by  depressions  indicating  the  seat  of  lacerations.  Its  opening  contracts 
slowly.  For  the  first  few  days  immediately  following  labour  it  readily 
admits  two  fingers,  hut  by  the  end  of  the  first  week  it  has  become  so 
narrow  as  to  render  difficult  the  introduction  of  one  finger.  At  the  same 
time  the  lower  uterine  segment  collapses,  and  what  remains  of  the  con- 
traction ring  comes  in  contact  with  the  upper  portion  of  the  cervical 
canal.     As  Webster  has  pointed  out,  there  is  no  doubt  that  the  structure 


304  OBSTETRICS 

which  is  usually  taken  for  the  internal  os  on  digital  examination,  really 
represents  the  lower  margin  of  the  contraction  ring  (Fig.  304).  The  changes 
in  this  portion  of  the  uterus  readily  explain  the  production  of  the  marked 
anteflexion  which  occasionally  characterizes  this  period. 

The  vagina  requires  some  time  to  recover  from  the  distention  to  which 
it  has  been  subjected.  In  the  first  part  of  the  puerperium,  it  is  repre- 
sented by  a  large,  smooth-walled  passage,  which  gradually  diminishes  in 
size,  though  it  rarely  returns  to  its  virginal  condition.  The  rugae  begin 
to  reappear  about  the  third  week.  The  vaginal  outlet  is  also  markedly  dis- 
tended, and  usually  bears  signs  of  more  or  less  extensive  laceration.  The 
hymen,  as  such,  has  disappeared,  and  its  place  is  taken  by  a  number  of 
small  tags  of  tissue,  which,  as  the  process  of  cicatrization  goes  on,  be- 
come converted  into  the  carunculce  myrtiformes,__which  are  characteristic 
of  the  vaginal  opening  of  parous  women.  The  labia  majora  and  minora 
become  flabby  and  atrophic,  as  compared  with  their  condition  before 
childbirth. 

Changes  in  the  Peritonaeum  and  Abdominal  Wall.— While  these  changes 
are  taking  place  in  the  uterus  and  vagina,  the  pelvic  peritonaeum  and  the 
structures  of  the  broad  ligaments  are  accommodating  themselves  to  the 
changed  condition  of  affairs.  For  the  first  few  days  after  labour  the 
peritonaeum  covering  the  uterus  is  arranged  in  folds,  which  soon  dis- 
appear. The  broad  ligament  is  much  more  lax  than  in  the  non-pregnant 
condition,  and  requires  a  considerable  time  to  recover  from  the  stretching 
and  loosening  to  which  it  has  been  subjected. 

As  a  result  of  prolonged  distention  due  to  the  presence  of  the  enlarged 
pregnant  uterus,  the  abdominal  walls  remain  soft  and  flabby  for  some  time. 
Except  for  the  presence  of  silvery  striae,  they  gradually  return  to  their  nor- 
mal condition  if  the  abdominal  muscles  have  retained  their  tonicity;  but 
when  this  is  markedly  impaired  they  never  regain  their  original  consist- 
ency, but  remain  lax  and  flabby.  In  not  a  few  instances,  particularly  in 
women  who  have  borne  a  number  of  children  in  rapid  succession,  there 
may  be  a  marked  separation  or  diastasis  of  the  recti  muscles,  so  that  a  consid- 
erable portion  of  the  abdominal  contents  is  covered  simply  by  peritonaeum, 
thinned-out  fascia,  and  skin. 

The  changes  occurring  in  the  breasts  are  very  characteristic,  and  will 
be  considered  in  Chapter  XVII. 

Clinical  Aspects  of  the  Puerperium. — Post-partum  Chill. — Not  infre- 
quently the  patient  may  have  a  more  or  less  violent  rigor  coming  on 
shortly  after  the  completion  of  the  third  stage  of  labour.  This  is  purely 
a  nervous  or  vaso-motor  phenomenon,  and  is  without  prognostic  signifi- 
cance. In  this  respect  it  stands  in  marked  contrast  to  a  chill  occurring 
later  in  the  puerperium,  which  nearly  always  indicates  the  onset  of  an 
acute  infectious  process  or  the  recrudescence  of  a  malarial  attack. 

Temperature. — Generally  speaking,  the  temperature  remains  practical- 
ly normal  during  the  puerperium;  hence  any  considerable  rise  should 
always  be  considered  as  a  sign  of  infection,  until  convincing  evidence  to 
the  contrary  can  be  adduced.  Not  infrequently  the  temperature  may  be- 
come slightly  elevated  towards  the  end  or  just  after  the  completion  of 


'CLINICAL  ASPECTS  OF  THE   PUERPERIUM  305 

a  difficult  Labour.  Under  such  circumstances  it  rarely  goes  above  LOO.40 
(38°  ('.).  usually  falls  to  normal  within  twelve  hours,  and  does  no1  rise 
again.  A  higher  temperature  during  labour  in  all  probability  indicates 
infection  of  the  liquor  amnii. 

Owing  to  the  fad  thai  slight  rises  of  temperature  occur  frequent lv 
during  the  puerperium  without  apparent  cause,  100.1  F.  (:5s  ( '.)  has 
arbitrarily  heen  chosen  as  the  upper  temperature  limit  for  the  normal 
puerperium,  any  rise  above  it  being  regarded  as  pathological. 

It  was  formerly  believed  that  the  establishment  of  the  lacteal  secretion 
on  the  third  or  fourth  day  of  the  puerperium  was  naturally  attended  by 
a  slight  rise  in  temperature.  Indeed,  so  prevalent  was  this  idea  that  in 
pre-antisq>tic  times  the  so-called  milk  fever  was  regarded  as  a  normal  phe- 
nomenon. But  at  present  we  no  longer  believe  in  the  existence  of  such 
a  pathological  entity,  and  whenever  the  temperature  exceeds  the  normal 
limit  at  this  time,  the  conscientious  obstetrician  should  fear  the  beginning 
of  an  infection  and  begin  to  look  for  the  errors  of  technique  which  may 
have  led  to  it. 

Pulse. — During  the  puerperium  the  pulse  is  usually  somewhat  slower 
than  at  other  times,  averaging  between  60  and  70.  In  nervous  women, 
however,  and  in  those  who  have  had  difficult  labours  or  have  suffered  any 
considerable  loss  of  blood,  a  more  rapid  rate  than  normal  is  not  infre- 
quent. In  a  certain  number  of  cases,  a  day  or  two  after  the  birth  of  the 
child,  the  pulse  becomes  markedly  slower,  and  not  infrequently  falls  to  50, 
40,  or  even  fewer  beats  to  the  minute.  Fehling  has  reported  a  case  in  which 
the  rate  was  only  36. 

Ordinarily  this  phenomenon  becomes  most  marked  on  the  second  or 
third  day,  after  which  the  pulse  becomes  quicker  and  attains  its  normal 
rate  by  the  end  of  the  first  week  or  ten  days.  The  slow  pulse  is  usually 
regarded  as  a  favourable  prognostic  sign,  whereas  a  rapid  heart  action, 
unless  it  can  be  accounted  for  by  haemorrhage  or  cardiac  disease,  should 
be  looked  upon  with  suspicion. 

This  puerperal  slowing  of  the  pulse  is  usually  regarded  as  a  physio- 
logical phenomenon.  Heil,  however,  in  1898,  stated  that  the  belief  was 
based  upon  faulty  observation.  He  affirmed  that  if  the  pulse  be  care- 
fully counted  in  the  same  patient  for  some  days  before  as  well  as  after 
labour,  it  will  be  found  slightly  quicker  in  the  puerperium  than  during 
pregnancy.  He  noted  the  puerperal  slow  pulse  in  only  12  per  cent  of 
his  cases.  Similar  investigations  undertaken  by  Yarnier  failed  to  confirm 
Heil's  conclusions,  since  the}7  showed  that  the  puerperal  slow  pulse  oc- 
curred in  72  per  cent  of  the  cases.  My  own  observations  show  that  the 
condition  occurs  more  frequently  than  noted  by  Heil  and  less  frequently 
than  by  Yarnier,  since  the  rate  was  subnormal  in  32  out  of  71  cases  (-A5  per 
cent)  observed  in  my  clinic. 

Numerous  theories  have  been  advanced  from  time  to  time  in  the 
attempt  to  explain  its  mode  of  production,  but  none  of  them  are  wholly 
satisfactory.  It  is  not  impossible  that  the  solution  is  quite  simple,  and 
that  the  condition  may  depend  upon  two  factors:  the  absolute  rest  of  the 
patient  in  bed,  together  with  the  great  diminution  in  work  which  the 


306  OBSTETRICS 

heart  is  called  upon  to  perform  after  the  elimination  of  the  utero-pla- 
cental  circulation.  Kehrer  attributed  the  slowing  in  great  part  to  the 
lowering  of  the  blood  pressure  following  delivery;  Schroeder,  to  the  sud- 
den  (Tnhinution  oT~th"e  vascular  area  after  the  utero-placental  circulation 
is  thrown  out  of  function;  Fritseh,  to  the  horizontal  position  and  rest  in 
bed;  Lohlein,  to  stimulation  of  the  vagus  or  other  nervous  influences; 
and  Olshausen,  to  the  absorption  of  various  products  set  free  in  the  blood 
during  the  involution  of  the  uterus. 

Changes  in  the  Blood. — It  is  usually  stated  that  there  is  a  slight  de- 
crease in  the  number  of  red  corpuscles  and  the  amount  of  haemoglobin 
immediately  after  delivery.  This  is  attributable  to  the  loss  of  blood  at 
the  time,  and  is  usually  compensated  for  within  the  first  week,  after  which 
the  normal  condition  is  restored. 

Hofbauer  has  directed  attention  to  the  occurrence  of  a  marked  leucoey- 
tosis  occurring  during  and  just  after  labour.  He  showed  that  the  leucocytes 
gradually  increase  in  number  from  the  onset  of  labour  and  reach  a  maxi- 
mum ten  or  twelve  hours  after  its  conclusion,  at  which  time  they  are  nearly 
twice  as  abundant  as  during  pregnancy.  Having  attained  their  acme,  they 
promptly  fall  to  normal,  rising  again  slightly  on  the  third  or  fourth  day, 
with  the  establishment  of  the  lacteal  secretion,  after  which  they  remain 
at  the  normal  level. 

After-pains. — In  primiparous  women  the  uterus  remains  in  a  state  of 
tonic  contraction  and  retraction  during  the  puerperium,  unless  it  has  been 
subjected  to  unusual  distention,  or  blood-clots  or  other  foreign  bodies  have 
been  retained  in  its  cavity,  as  a  consequence  of  which  active  contractions 
occur  in  the  effort  to  expel  them.  In  multiparous  women,  on  the  other 
hand,  the  uterus  has  lost  part  of  its  initial  tonicity,  so  that  persistent  con- 
traction and  retraction  cannot  be  maintained,  and  it  therefore  contracts 
and  relaxes  at  intervals,  the  contractions  giving  rise  to  painful  sensations, 
which  are  known  as  after-pains.  In  mamr  patients  these  are  particularly 
noticeable  when  the  child  is  put  to  the  breast,  and  may  last  for  many  days, 
but  ordinarily  they  lose  their  intensity  and  become  quite  bearable  after 
the  twenty-four  hours  immediately  following  delivery. 

Lochia. — During  the  first  part  of  the  puerperium  there  occurs  normally 
a  variable  amount  of  vaginal  discharge — the  lochia.  For  the  first  few 
days  after  delivery  it  consists  in  great  part  of  blood — lochia  rubra;  after 
three  or  four  clays  it  becomes  paler — lochia  serosa;  and  after  the  tenth  day, 
owing  to  a  marked  admixture  with  leucocytes,  it  assumes  a  whitish  or  yel- 
lowish-white colour — lochia  alba.  It  is  alkaline  in  reaction,  and  has  a  pecu- 
liar fleshy  odour,  suggesting  fresh  blood.  Foul-smelling  lochia  indicate 
infection  with  putrefactive  bacteria.  In  many  instances  the  reddish  colour 
is  preserved  for  several  weeks,  but  when  it  persists  for  a  longer  period,  it 
indicates  imperfect  involution  of  the  uterus  or  the  retention  of  portions  of 
the  after-birth.  When  examined  under  the  microscope  during  the  first  few 
days,  the  lochia  consist  of  red  blood-corpuscles,  leucocytes,  fatty  epithelial 
cells,  and  shreds  of  degenerated  decidual  tissue. 

Micro-organisms  can  always  be  demonstrated  in  the  discharge  gathered 
at  the  vulva,  but  are  not  always  present  when  it  is  obtained  from  other 


CLINICAL    ASPECTS   OF   THE    PUERPERIUM  307 


portions  of  the  generative  tract.    The  investigations  of  Doderlein,  BLroni 
Doderlein  and  Winternitz,  myself,  and  others  have  shown  that  the  lochia 
obtained  directly   from   the   dterine  cavity  do  noi   contain   bacteria,  e 
cepl   in  cases  of  infection,  whereas  micro-organisms  arc  always  presenl    in 

large  □ bers  in  the  vaginal  discharge.    The  early  work  of  KLehrer,  Karew- 

ski,  and  others,  appeared  to  indicate  that  the  vaginal  lochia  nearly  always 
contained  pyogenic  bacteria,  since  small  quantities  of  the  discharge,  when 
injected  under  the  patient's  skin,  gave  rise  to  abscess  formation.  The  more 
recent  investigations  of  Krdnig,  however,  have  demonstrated  that  these 
conclusions  were  erroneous,  and  that  the  vaginal  lochia,  although  rich  in 
harmless  parasites,  do  not  contain  pyogenic  organisms,  with  the  exception 
of  gonococci,  unless  the  uterus  is  the  seat  of  infectious  processes.  The 
same  investigator  also  showed  that  the  bacterial  flora  of  the  vagina  under- 
goes a  marked  change  during  the  puerperium.  During  pregnancy  bacilli 
predominate,  but  are  in  great  part  replaced  by  cocci  during  the  puerperium. 
This  change  is  probably  due  to  the  altered  reaction  of  the  secretion,  which 
is  markedly  acid  before,  and  alkaline  after  labour. 

The  amount  of  lochial  discharge  varies  in  different  individuals.  Gass- 
ner  estimated  its  average  quantity  at  1,485  cubic  centimetres,  but  in  many 
cases  it  is  less,  and  occasional^  much  more  profuse.  In  practice  an  ap- 
proximate idea  of  its  amount  may  be  gained  from  the  frequency  with 
which  it  is  necessary  to  change  the  dressings  during  the  twenty-four  hours. 

General  Functions. — The  function  of  the  skin  is  markedly  accentuated 
during  the  puerperium,  as  is  demonstrated  by  the  profuse  sweating  which 
frequently  characterizes  this  period.  It  is  most  marked  at  night,  and  it 
is  not  unusual  for  the  patient  to  awake  from  a  sound  sleep  to  find  her 
night-gown  drenched  with  perspiration. 

The  appetite  is  usually  diminished  during  the  first  few  days  after  la- 
bour, ana  the  "'patient  experiences  very"  little  desire  for  nutritious  food. 
At  the  same  time,  owing  to  the  marked  diaphoresis  and  the  quantity  of 
fluid  lost  through  the  lochial  discharge,  thirst  is  considerably  increased. 

The  bowels  are  nearly  always  constipated  during  the  first  part  of  the 
puerperium.  This  is  due  partly  to  the  fact  that  the  patient  eats  but  little 
solid  food,  but  principally  to  the  marked  relaxation  of  the  abdominal  walls 
and  their  consequent  inability  to  aid  in  evacuating  the  intestinal  contents. 

Urine. — The  urine  is  generally  somewhat  increased  in  amount  during 
the  first  few  days  of  the  puerperium,  but  in  normal  cases  the  quantity  of 
urea  is  slightly  less  than  at  other  times. 

In  the  majority  of  cases  the  examination  of  specimens  of  urine,  re- 
moved by  catheterization  immediately  after  the  completion  of  the  third 
stage  of  labour,  shows  a  slight  amount  of  albumin  and  numerous  hyalin 
casts,  even  though  both  may  have  been  absent  throughout  pregnancy. 
Tn  1.000  of  my  own  cases  which  were  studied  with  this  point  in  view,  albu- 
min was  noted  in  62.9  per  cent  and  casts  in  19.4(5  per  cent,  and  similar  re- 
sults have  been  obtained  by  Temesvary  and  others.  This  is  a  transient  phe- 
nomenon resulting  from  the  systemic  strain  caused  by  labour,  and  has  no 
prognostic  significance. 

Occasionally  a  small  amount  of  sugar  may  be  found  in  the  urine  on 
21 


308  OBSTETRICS 

the  second  or  third  day  of  the  puerperium,  coincidently  with  the  estab- 
lishment of  the  lacteal  secretion.  Careful  investigation  shows  that  the 
reaction  is  due  to  the  presence  of  lactose,  or  milk-sugar,  which  is  supposed 
to  be  absorbed  from  the  mammary  glands,  so  that  the  condition  has  noth- 
ing to  do  with  diabetes.  Ney  observed  it  in  77  per  cent  of  his  cases,  while 
McCann  and  Turner  detected  it  in  small  quantities  in  every  case  which 
they  examined.  In  my  own  clinic  it  was  present  in  only  a  small  propor- 
tion of  the  cases — 2.6  per  cent.  For  a  full  discussion  of  the  question  the 
reader  is  referred  to  the  dissertation  of  Gusnar. 

Couvelaire  and  Scholten  have  recently  demonstrated  that  there  is  a 
marked  increase  in  the  amount  of  acetone  in  the  urine  immediately  after 
labour,  which  disappears  within  the  next  three  days.  The  last-named  in- 
vestigator noted  it  in  94  per  cent  of  his  cases,  and  found  that  it  was  most 
abundant  after  difficult  and  prolonged  labours.  He  attributes  its  production 
to  the  excessive  breaking  up  of  carbohydrates  resulting  from  the  increased 
muscular  activity  incident  to  parturition. 

Not  infrequently  there  is  a  marked  tendency  towards  retention  of  the 
urine  during  the  first  few  days  of  the  puerperium,  and  the  distended  blad- 
der can  frequently  be  distinguished  as  a  fluctuant  tumour  above  the  um- 
bilicus. The  retention  may  result  from  numerous  causes,  but  is  particu- 
larly apt  to  follow  operative  or  difficult  labours;  and  under  such  circum- 
stances may  be  attributable  to  contusions  or  other  slight  lesions  of  the 
urethra.  In  other  cases  it  is  probably  caused  by  the  diminished  intra- 
abdominal pressure  which  allows  a  greater  quantity  of  urine  to  accumulate 
in  the  bladder  than  under  other  conditions,  as  well  as  by  the  flaccidity  of 
the  abdominal  walls  and  the  consequent  difficulty  of  bringing  them  into 
play  during  urination.  In  not  a  few  cases  it  is  due  to  the  fact  that  pos- 
sibly at  any  time  the  patient  is  unable  to  evacuate  the  bladder  in  the  re- 
cumbent position. 

Loss  of  Weight. — In  addition  to  the  loss  of  6  to  6^  kilos,  which  results 
from"  the  evacuation  of  the  contents  of  the  uterus,  it  is  generally  stated 
that  there  is  a  still  further  loss  of  body  weight  during  the  puerperium, 
which  according  to  Gassner  amounts  to  4,500  grammes  in  the  first  week. 
Heil  estimates  it  at  2,000,  and  Klemmer  at  only  900  grammes.  This  ap- 
parent contradiction  is  due  to  the  fact  that  Gassner's  results  were  obtained 
at  a  time  when  the  diet  was  greatly  restricted,  but  at  present,  when  it 
is  more  liberal,  the  loss  of  weight  is  much  less,  and  in  many  instances 
does  not  occur  at  all  if  sufficient  food  be  taken.  In  normal  cases  it  is 
nearly  always  regained  by  the  end  of  the  puerperium. 

Care  of  the  Patient  during  the  Puerperium. — Attention  immediately 
after  Labour. — After  carefully  examining  the  placenta  immediately  after 
its  expulsion,  to  make  sure  that  it  is  intact,  the  physician  should  devote  his 
attention  to  watching  the  condition  of  the  uterus.  At  this  time  it  should 
form  a  hard,  round,  resistant  tumour,  whose  upper  margin  lies  below  the 
umbilicus.  As  long  as  it  resembles  a  cricket-ball  in  consistence  there  is 
no  danger  of  post-partum  haemorrhage.  But  if  it  becomes  soft  and  flabby 
there  is  imminent  danger  of  such  an  occurrence,  unless  proper  measures 
are  taken  at  once  to  guard  against  it.    For  this  "purpose  the  uterus  should 


CARET  <)F  THE    PATIENT   DURING   THE   PDERPERIUM  309 

be  palpated  through  the  abdominal  walls  immediately  after  the  conclusion 
of  the  third  stage,  and  if  ii  is  found  to  be  Srmly  contracted,  the  same 
manceuvre  should  be  repeated  al  intervals  of  a  few  minutes.  II',  however, 
any  tendency  towards  relaxation  is  detected,  the  organ  should  be  grasped 
through  the  abdominal  walls  and  vigorously  kneaded  until  ii  remains  persist- 
ently contracted;  al  the  same  time  ergo!  should  be  administered  hypo- 
dermically. 

In  normal  eases,  even  although  there  may  be  no  tendency  towards 
haemorrhage,  the  uterus  should  be  palpated  at  intervals  for  the  first  hour 
after  the  expulsion  of  the  placenta;  but  if  satisfactory  contractions  do 
not  occur  at  once,  its  behaviour  should  be  carefully  watched  for  at  least  an 
hour  after  these  have  been  induced.  The  physician  should  never  leave  the 
pal  ient  immediately  after  the  completion  of  labour,  even  if  it  has  been  per- 
fectly normal,  but  should  remain  within  call  for  at  least  an  hour,  so  as  to  be 
ready  should  any  complication  arise.  If  the  patient  has  a  competent  trained 
nurse,  the  duty  of  watching  the  uterus  may  be  delegated  to  her;  but  the 
physician  should  not  leave  the  house  until  he  has  made  a  final  examination 
and  is  satisfied  that  all  reasonable  danger  of  haemorrhage  has  passed. 

Toilet  of  the  Vulva. — Immediately  after  the  birth  of  the  placenta,  the 
soiled  linen  having  been  removed  from  beneath  the  patient,  the  buttocks 
and  external  genitalia  are  cleansed  with  hot  water  and  soap  and  bathed 
with  a  l-to-2,000  bichloride  solution.  A  sterilized  vulval  pad,  made  of 
cotton  wrapped  in  gauze,  is  then  applied  over  the  genitalia  and  held  in 
place  by  a  "  T  "  bandage,  being  replaced  by  a  clean  one  whenever  neces- 
sary. The  number  of  pads  required  in  the  twenty-four  hours  varies  accord- 
ing to  the  amount  of  lochial  discharge,  and  affords  a  fairly  accurate  means 
of  estimating  its  quantity.  Each  time  the  pads  are  changed,  and  after  each 
movement  of  the  bowels,  the  genitalia  should  be  washed  with  cotton 
pledgets  soaked  in  bichloride  solution.  Ordinary  sponges  should  never  be 
used  for  this  purpose.  The  parts  should  be  washed  from  above  downward, 
so  as  to  avoid  contamination  from  the  rectum. 

The  vulval  pad  not  only  absorbs  the  lochia  and  prevents  contamina- 
tion of  the  vulva  from  without,  but  also  makes  it  difficult  for  the  patient 
to  touch  her  genitalia,  a  practice  very  common  among  the  uneducated 
classes,  and  one  that  occasionally  gives  rise  to  infection. 

Binder. — Many  authorities  recommend  that  a  tightly  fitting  binder  of 
unbleached  muslin,  reaching  from  the  trochanters  to  above  the  umbilicus, 
be  applied  immediately  after  delivery,  since  they  hold  that  it  exerts  a 
beneficial  effect  upon  the  involution  of  the  uterus,  makes  the  patient  more 
comfortable,  and  tends  to  restore  her  figure  to  its  original  condition.  Per- 
sonally, I  am  not  in  favour  of  its  employment,  and  do  not  believe  that 
it  serves  any  of  the  purposes  for  which  it  is  recommended.  On  the  other 
hand,  I  am  strongly  of  the  opinion  that  it  occasionally  gives  rise  to  retro- 
version or  retroflexion^ol-the  enlarged  and  soft  uterus,  especially  if  rTTje" 
applied  sufficienfTysnuglv  to  exert  compression.  This  objection,  however, 
does  not  hold  good  after  the  organ  has  descended  into  the  pelvic  cavity — 
that  is.  after  the  tenth  dav.  From  this  time  o_n  a  well-fitting  bandage  can 
do  no  harm,  and  some  patients  find  that  it  adds  considerably  to  their  com- 


310  OBSTETRICS 

fort  by  supporting  the  lax  abdominal  walls  when  they  first  begin  to  sit  up. 
Nor  can  I  find  any  evidence  of  its  value  in  restoring  the  figure,  which  will 
gradually  return  without  its  use,  provided  the  tonicity  of  the  abdominal 
muscles  be  retained;  but  when  this  is  seriously  impaired  I  know  nothing 
that  will  bring  about  the  desired  result,  although  gentle  massage  applied 
later  may  do  something  towards  it. 

After-pains. — As  after-pains  usually  occur  in  multipara?,  but  only  in 
primiparse  when  the  uterus  has  been  subjected  to  undue  distention,  it  is 
not  usually  necessary  to  provide  for  their  treatment  after  the  birth  of  the 
first  child.  On  the  other  hand,  after  the  delivery  of  a  multiparous  patient, 
it  is  advisable  to  leave  with  the  nurse  several  tablets  of  \  grain  of  morphine 
and  yip-  grain  of  atropine,  with  instructions  to  administer  them  by  the 
mouth  at  intervals  of  four  or  six  hours,  if  the  pains  be  severe. 

Best  and  Quiet. — As  soon  as  the  patient  has  been  made  comfortable,  the 
room  should  be  darkened  and  she  should  be  encouraged  to  go  to  sleep. 
The  relatives  should  be  excluded,  and  the  nurse  should  bathe  and  dress  the 
baby  in  an  adjoining  apartment,  if  there  is  one  at  her  disposal.  The  pa- 
tient should  be  kept  as  quiet  as  possible  for  the  first  ten  days,  and  during 
this  period,  as  a  rule,  only  the  immediate  members  of  the  family  should  be 
admitted  to  see  her.  Moreover,  if  these  are  numerous,  strict  instructions 
should  be  given  the  nurse  as  to  the  number  of  visitors  each  day. 

Diet. — Formerly  it  was  the  custom  to  restrict  to  a  minimum  the  diet 
of  the  puerperal  woman,  and  as  has  already  been  said,  this  limitation  goes 
far  to  explain  the  loss  of  weight  which  was  frequently  observed  during  the 
first  few  days.  At  present,  however,  a  more  liberal  allowance  is  customary, 
and  the  j)atient  is  encouraged  to  take  plenty  of  plain  nourishing  food. 

If  not  nauseated,  she  should  be  given  a  glass  of  milk  or  a  cup  of  tea 
soon  after  labour.  For  the  first  few  days  the  appetite  is  not  vigorous, 
but  small  quantities  of  easily  digested  food  may  be  taken  at  frequent 
intervals.  I  usually  give  the  nurse  the  following  directions:  Fo#the  first 
twenty-four  hours,  water,  milk,  coffee,  tea,  or  cocoa,  and"  buttered  or  soft 
toast.  On  the  second  and  third  days  the  same,  with  the  addition  of  sim- 
ple soups  or  bouillon,  boiled  or  poached  eggs,  raw  or  stewed  oysters,  and 
wine  jelly.  On  the  fourth  and  fifth  days  as  above,  with  the  addition  of 
chicken,  baked  potatoes,  and  rice,  after  which  the  ordinary  diet  should 
be  gradually  resumed. 

Temperature. — The  temperature  should  be  carefully  watched  during 
the  first  week  of  the  puerperium,  as  fever  is  usually  the  first  symptom  of 
the  onset  of  an  infectious  process.  If  the  patient  be  in  charge  of  a 
trained  nurse,  it  should  be  taken  four  times  daily — at  8  a.  m.,  12  m.,  1 
p.  m.,  and  8  p.  m.,  and  recorded  upon  a  suitable  chart.  The  physician 
should  be  immediately  notified  if  it  rises  above  100°.  But  when  the 
nurse  is  ignorant,  the  temperature  should  be  taken  by  the  physician  him- 
self, morning  and  evening,  for  the  first  five  days.  This,  of  course,  means 
that  during  that  time  he  must  visit  the  patient  twice  a  day.  once  a 
day  for  the  following  two  or  three  days,  and  afterward  at  less  frequent 
intervals.  But  when  the  nurse  is  competent,  a  single  visit  a  day  will  suf- 
fice, unless  untoward  symptoms  develop,  as  the  plrysician  can  rely  upon 


CARE  OF  THE   PATIENT   DURING   THE   PUERPERIUM  311 

being  notified  promptly  of  any  change.  II  is  always  better,  however, 
whenever  possible,  thai  the  patient  should  be  seen  within  the  firsl  twelve 
hours  following  delivery. 

Urination. — The  patient  should  be  encouraged  to  urinate  within  the 
first  six  hours.  When  she  is  unable  to  do  so,  the  catheter  should  not  he 
employed  until  the  hladder  forms  a  marked  tumour  above  the  symphysis, 
and  not  even  then  until  the  patient  has  attempted  to  urinate  in  a  sitting 
posit  ion ;  inasmuch  as  many  women  are  unable  to  use  a  bed-pan.  I  consider 
the  change  in  position  much  less  dangerous  than  catheterization,  as  the 
latter,  no  matter  how  carefully  performed,  always  carries  with  it  some 
risk  of  infection  and  of  a  consequent  cystitis.  Moreover,  in  not  a  few 
cases,  the  procedure,  when  once  commenced,  must  be  continued  for  a  num- 
ber of  days,  a  condition  of  affairs  which,  leaving  out  of  account  the  danger 
of  infection,  becomes  very  onerous  to  the  physician,  unless  he  has  a  com- 
petent nurse  in  charge. 

When,  however,  catheterization  becomes  absolutely  necessary,  the 
genitalia  having  been  first  exposed  and  bathed  with  a  bichloride  or  boric 
solution,  a  glass  catheter,  which  has  been  sterilized  by  boiling,  should 
be  introduced  by  carefully  disinfected  fingers;  or,  better  still,  it  should 
be  grasped  with  a  piece  of  freshly  boiled  cotton,  so  as  to  prevent  its  com- 
ing in  contact  with  the  fingers  at  all.  At  the  present  day,  to  catheterize 
a  woman  under  a  sheet  or  by  the  sense  of  touch  is  not  justifiable. 

Bowels. — In  view  of  the  sluggishness  of  the  bowels  in  the  puerperium, 
a  mild  cathartic  should  be  administered  on  the  morning  of  the  second  day, 
unless  they  have  previously  been  evacuated  spontaneously.  For  this  pur- 
pose I  generally  employ  half  an  ounce  of  Eochelle  salts  in  a  small  quan- 
tity of  water,  half  a  bottle  of  the  effervescent  citrate  of  magnesia,  or,  if 
the  patient  will  consent  to  take  it,  half  an  ounce  of  castor-oil. 

After  the  preliminary  cathartic,  the  bowels  should  be  moved  once 
daily.  If  a  spontaneous  action  does  not  occur*,  the  administration  of  the 
fluid  extract  of  cascara  at  bedtime,  in  20-  to  60-minim  doses,  or  1  or 
2  drams  of  the  aromatic  elixir,  according  to  the  susceptibility  of  the 
patient,  is  indicated.  Sometimes  a  pill  containing  aloin,  belladonna,  and 
strychnine  proves  very  satisfactory. 

Care  of  the  Nipples. — Details  concerning  the  care  of  the  nipples  will 
be  given  in  Chapter  XVII,  but  the  physician  should  be  careful  to  impress 
upon  the  nurse  the  necessity  of  observing  aseptic  precautions  in  dealing 
with  them;  and  she  should  be  directed  to  report  immediately  the  appear- 
ance of  fissures,  as  their  proper  treatment  will  usually  prevent  mammary 
infection  and  the  consequent  danger  of  mastitis. 

Time  for  Getting  Up. — It  is  a  time-honoured  custom  to  allow  the  puer- 
peral woman  to  sit_jrpon  the  tenth  day.  This  rule,  however,  should  not 
be  slavishly  followed/and  every  patient  should  be  kept  in  bed  until  the 
fundus  of  the  uterus  has  disappeared  behind  the  symphysis  pubis.  This 
frequently  occurs  by  the  tenth  day,  occasionally  a  clay  or  so  earlier,  but 
very  often  not  until  some  clays  later.  Generally  speaking,  a  two-weeks' 
rest  in  bed  is  not  excessive. 

Ivustner  has  lately  advocated  the  practice  of  allowing  the  patient  to 


312  OBSTETRICS 

get  tip  on  the  third  or  fourth  day,  and  states  that  he  has  seen  no  ill  conse- 
quences follow  such  a  procedure.  His  suggestion  was  promulgated  before 
the  German  Gynaecological  Congress  in  1899,  but  was  not  favourably  re- 
ceived, no  one  who  spoke  upon  the  subject  indorsing  his  views. 

It  is  also  advisable  to  give  rigid  directions  as  to  the  length  of  time 
the  patient  should  remain  out  of  bed.  I  have  found  it  a  convenient  rule 
to  direct  that  she  should  sit  up  for  one  hour  on  the  first  day,  two  hours 
on  the  second,  and  to  increase  the  time  by  an  hour  each  day  until  she  is 
able  to  be  up  all  the  time.  She  should  be  kept  in  her  room  until  the  ex- 
piration of  the  third  week,  and  allowed  to  move  about  on  the  floor  on 
which  she  was  confined  during  the  fourth  week.  She  should  not  be  per- 
mitted to  go  downstairs  until  the  expiration  of  this  period,  as  it  is  a  mat- 
ter of  experience  that  the  average  woman  cannot  be  prevented  from  as- 
suming the  ordinary  duties  of  her  household  after  she  has  once  gone  down- 
stairs; whereas  as  long  as  she  is  kept  on  one  floor  she  is  usually  amenable 
to  the  direction  of  her  physician. 

Final  Examination. — At  the  end  of  the  third  or  the  beginning  of  the 
fourth  week  the  patient  should  be  subjected  to  an  internal  examination, 
and  the  condition  of  the  perinseum,  uterus,  and  appendages  carefully  in- 
vestigated. Not  infrequently  the  uterus  will  be  found  displaced,  when  the 
introduction  of  a  properly  fitting  pessary  may  lead  to  a  prompt  cure; 
whereas  if  treatment  be  deferred  until  symptoms-  appear,  the  condition 
may  not  be  relieved  so  readily.  In  other  cases,  various  abnormalities  may 
be  noted,  which  should  be  treated  before  the  patient  is  discharged,  and 
occasionally  it  may  be  necessary  to  warn  her  or  her  husband  that  opera- 
tive procedures  will  be  required  in  the  future.  If  everything  is  perfectly 
normal,  it  is  a  great  comfort  to  the  patient  to  be  assured  of  the  fact; 
whereas  if  any  abnormality  is  noted  and  the  attention  of  some  responsible 
member  of  the  family  be  directed  to  it,  the  physician  may  save  himself 
from  censure  if  a  subsequent  examination  be  made  by  some  one  else. 

LITERATURE 

Couvelaire.     De  l'acetonurie  transitoire  du  travail  de  l'accouchement.    Annales  de  Gyn. 

et  d'Obst.,  1899,  li,  353-367. 
Doderleix.     Untersuchungen  liber  das  Vorkommen  von  Spaltpilzen  in  den  Lochien  des 

Uterus  und  der  Vagina,  etc.     Arch.  f.  G-yn.,  1887,  xxxi,  412-447. 
Das  Scheidensekret.     Leipzig,  1892. 
Doderlein  und  Wixternitz.     Die  Bakteriologie  der  puerperalen  Sekrete.     Hegar's  Bei- 

trage  zur  Geb.  u.  Gyn.,  1900,  iii,  161-175. 
Fehling.     Physiologie  und  Pathologie  des  Wochenbetts.     Stuttgart,  1890. 
Friedlander.     Physiol.-anat.  Untersuchungen  iiber  den  Uterus.     Leipzig,  1870. 
Fritsch.     Die  puerperale  Pulsverlangsamung.     Archiv  f.  Gyn.,  1875,  viii,  383-390. 
Gassner.     Ueber  die  Veranderungen  des  Korpergewichtes  bei  Schwangeren,  Gebarenden 

u.  Wochnerinnen.     Monatsschr.  f.  Geburtskunde,  1862.  xv,  1-68. 
Gusnar.     Beitrage  zur  Lactosurie  der  Wochnerinnen.     D.  I.,  Halle,  1895. 
Heil.      Untersuchungen  iiber  die  Korpergewichtsverhaltnisse  normaler  Wochnerinnen. 

Arch.  f.  Gyn.,  1896,  li,  18-32. 
Giebt  es  eine  physiologische   Pulsverlangsamung  im  Wochenbette  ?     Archiv  f.  Gyn., 

1898,  liv,  265-280. 


THE    PUEKPERIUM  313 

Hofbauer.    Zur  Physiologic  des   Puerperiums.     Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  v, 

Ergfinzungsheft,  52-57. 
Karewski.    Exp.  Untersuchungen  iiber  die  Einwirkungen  der  puerperalen  Sekrete  auf 

dem  thierischen  Organismus.    Zeitschr.  f.  Geb.  u.  Gyn.,  1S82,  \ii.  331. 
Kehrer.     Ueber  die  Ver&nderungen  der  Pulscurve  im  Puerperium.     Heidelberg,  1886. 

Wirkung  der  Lochien  auf  lebendes  Gewebe.     Miiller's  Handbuch  der  Geb..  i,  545,  1888. 
Klemmer.     Untersuchungen  iiber  den  Stoffwechsel  der  Wochnerinnen  und  die  zweck- 

miissigste  Diiit  derselben.     Winckel's  Berichte  and  Arbeiten,  1870,  ii,  155-186. 
lvRoNici.     Bakteriologie  des  Genitalkanales  der  schwangeren,  kreissenden  und  puerperalen 

Frau.     Leipzig,  1897,  54-64  und  196-201. 
Beitrag  zuin  anat.  Verhalten  der  Schleimhaut  der  Cervix  und  des  Uterus  wahrend  der 

Sehwangerschaft  und  im  Friihwochenbett.     Arch.  f.  Gyn.,  1901,  lxiii,  26-38. 
Kundrat  und  Engelmann.     Untersuchungen  liber  die  Uterusschleimhaut.     Strieker's 

med.  Jahrb.,  1873. 
Kustner.     1st  einer  gesunden  Wochnerin  eine  protrahirte  Bettruiie  dienlich  ?    Verb,  der 

deutschen  Gesellsch.  f.  Gyn.,  1899,  viii,  525-535. 
Leopold.     Studien  iiber  die  Uterusschleimhaut.  etc.     Berlin,  1878.     (Archiv  f.  Gyn.,  xi 

und  xii.) 
Lohleix.     Ueber  das  Verhalten  des  Herzens  bei  Schwangeren  und  Wochnerinnen.     Ber- 
liner Zeitschr.  f.  Geb.  u.  Frauenkr.,  1876,  i,  482-516. 
MgCasn  and  Turner.     On  the  Occun-ence  of  Sugar  in  the  Urine  during  the  Puerperal 

State.     Trans.  London  Obst.  Soc,  1892,  xxxiv,  473-490. 
Ney.     Ueber  das  Vorkommen  von  Zucker  im  Harne  der  Schwangeren,  etc.     Archiv  f. 

Geb.  u.  Gyn.,  1889,  xxxv,  239-256. 
Olshausen.    Ueber  die  Pulsverlangsamung  im  Wochenbette  und  ihre  Ursache.    Centralbl. 

f.  Gyn.,  1881,  49-53. 
Pels  Leusden.     Ueber  die  serotinalen  Riesenzellen,  etc.     Zeitschr.  f.  Geb.  u.  Gyn.,  1897, 

xxxvi,  1-61. 
Sanger.     Die  Riickbildung  der  Muscularis  des  puerperalen  Uterus.     Beitrage  zur  path. 

Anat.  und  klin.  Med.,  von  Wagner's  Schiilern,  1887,  134. 
Scholten.    Ueber  puerperale  Acetonurie.     Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1900,  iii, 

439-451. 
Schroeder.     Lehrbuch  der  Geburtshiilfe,  XIII.  Aufl.,  1889,  268. 
Temesvary.     Physiologie  des  Wochenbettes.     Sanger-Herff  Encyklopadie  der  Geb.  u. 

Gyn.,  1900,  498-502. 
Varnier.     Du  ralentissement  du  pouls  pendant  les  suites  des  couches.     Annales  de  Gyn. 

et  d'Obst.,  1899,  li,  30-47. 
Webster.     The  Anatomy  of  the  Female  Pelvis  during  the  Puerperium.     Researches  in 

Female  Pelvic  Anatomy,  Edinburgh,  1892,  1-55. 


CHAPTEE   XVII 
THE  NEWLY  BORN  CHILD 

INTokmally  the  newly  born  child  begins  to  cry  almost  immediately 
after  its  exit  from  the  vulva.  This  act  indicates  the  establishment  of 
respiration,  which  is  accompanied  by  important  modifications  in  the  cir- 
culatory system. 

Circulatory  Changes. — As  soon  as  the  lungs  begin  to  function,  the 
blood  which  is  brought  by  the  inferior  vena  cava  to  the  right  auricle  no 
longer  passes  through  the  foramen  ovale,  but  makes  its  way  directly  into 
the  right  ventricle,  whence  it  is  carried  to  the  lungs  by  means  of  the 
pulmonary  arteries.  Coincident  with  the  establishment  of  the  pulmo- 
nary circulation,  there  ensues  a  marked  increase  in  the  pressure  in  the 
left  auricle.  This  in  turn  brings  about  the  closure  of  the  valve  of  the 
foramen  ovale,  which  after  a  few  months  fuses  with  the  periphery  of  the 
opening.  At  the  same  time  the  blood  ceases  to  flow  through  the  ductus 
Botalli  into  the  aorta,  and  the  canal  itself  gradually  becomes  obliterated. 
According  to  Strassmann,  the  primary  cause  for  this  change  is  to  be  found 
in  the  fact  that  the  ductus  traverses  the  wall  of  the  aorta  in  an  oblique 
direction,  so  that  as  soon  as  the  pressure  in  the  aortic  arch  is  increased,  its 
wall  acts  as  a  valve  and  occludes  the  distal  end. 

The  circulation  through  the  umbilical  arteries  ceases  a  few  minutes 
after  birth,  when,  owing  to  the  contraction  of  their  thick  muscular  walls, 
the  lumina  become  practically  obliterated.  It  is  usually  stated  that  after 
the  establishment  of  the  pulmonary  circulation  the  general  arterial  pres- 
sure  is  dimmished  to  such  an  extent  that  it  is  insufficient  to  force  the_ 
"blood  tlwugh  them.  The  investigations  of  Ahlfeld  have  shown  that  this 
is  not  the  "case,  and  would  rather  indicate  that  the  contraction  of  the 
arteries  is  brought  about  by  the  stimulation  resulting  from  the  cooling  of 
the  cord  immediately  after  birth.  That  this  explanation  is  correct  is  demon- 1 
strated  by  the  fact  that  the  circulation  can  be  re-established  by  immersing 
the  child  in  a  warm  bath  and  thus  doing  away  with  this  factor. 

This  point  is  of  practical  importance  in  view  of  the  fact  that  occasion- 
ally, when  the  cord  has  not  been  ligated  sufficiently  tightly,  secondary 
haemorrhage  occurs  from  its  foetal  end  after  the  child  has  been  placed  in 
a  warm  bed.  To  guard  against  such  an  occurrence  the  cord  should  always 
be  reinspected  within  an  hour  after  deliverv. 

The  child  passes  urine  almost  immediately  after  birth,  and  not  infre- 
314 


THE   NEWLY   BORN   CHILD  315 

quently  while  in  the  act  of  being  born.     In  a  considerable  number 
cases  a  certain  amount  of  meconium  is  also  discharged.    As  a  result  of  the 
cooling  of  the  surface  of  the  child  <»n  coming  into  the  world,  its  tem- 
perature becomes  reduced  by  a  few  degrees,  which,  however,  are  promptly/ 
regained  after  it  has  beeu  bathed  and  placed  in  a  warm  bed.     For  the  lirst^ 
few  days  of  life  the  temperature  is  in  very  unstable  equilibrium,  and  a 
slighl  cause  may  give  rise  to  a  considerable  elevation. 

Care  of  the  Umbilical  Cord. — As  has  already  been  said,  the  umbilical 
cord  should  not  be  ligated  until  it  has  ceased  to  pulsate,  unless  there  is 
gOme  urgent  reason  to  the  contrary.  Two  ligatures  of  sterilized  bobbin 
should  be  placed  about  it  and  tightly  tied,  one  about  1  centimetre  from 
the  surface  of  the  abdomen,  and  the  other  2  centimetres  beyond  the  first, 
the  cord  being  then  cut  between  them  with  a  pair  of  sterile  scissors. 

Owing  to  the  absence  of  circulation,  what  is  left  of  the  cord  undergoes 
mummification,  and  gradually  a  line  of  demarcation  appears  just  beyond 
the  skin  surface  of  the  abdomen,  until  in  a  few  days  the  stump  sloughs  off, 
leaving  behind  a  small,  granulating  wound,  which,  after  healing,  forms 
the  umbilicus. 

The  separation  of  the  cord  usually  takes  place  within  the  first  week 
after  birth,  but  it  is  not  unusual  for  it  to  require  a  longer  time,  and  occa- 
sionally several  weeks  may  elapse  before  it  occurs.  In  the  very  rare  in- 
stances in  which  the  stump  is  still  adherent  at  the  end  of  the  puerperium, 
it  may  become  necessary  to  clip  it  off  with  a  pair  of  scissors. 

Formerly  the  care  of  the  cord  was  considered  a  very  trivial  matter, 
and  the  midwife,  as  a  rule,  would  wrap  it  in  a  piece  of  greased  or  singed 
linen,  after  which  little  or  no  attention  was  paid  to  it.  This  practice, 
however,  and  the  total  neglect  of  aseptic  precautions,  frequently  resulted 
in  an  infection  which  was  transmitted  through  the  umbilical  vessels,  and 
from  which  in  times  past  large  numbers  of  children  have  perished.  Even 
now,  when  the  necessity  for  proper  treatment  is  generally  recognised,  um- 
bilical infections  are  not  of  infrequent  occurrence,  a>  i-  -hown  by  the 
monograph  of  Eross.  Moreover,  it  may  be  stated  as  a  general  rule  that, 
whenever  children  die  without  any  appreciable  cause  within  a  few  weeks 
after  birth,  such  an  infection,  should  be  suspected,  and  the  examination 
of  the  intra-abdominal  portion  of  the  umbilical  vessels  will  usually  show 
that  they  are  filled  with  purulent  thrombi,  in  which  pyogenic  micro-organ- 
isms can  be  demonstrated.  In  view,  therefore,  of  the  not  inconsiderable 
danger  of  infection  from  this  source,  strict  aseptic  precautions  should  be 
observed  in  caring  for  the  cord.  The  reader  is  referred  to  Ploss's  work 
for  interesting  details  concerning  its  treatment  in  various  countries  and 
by  aboriginal  peoples. 

After  making  the  mother  comfortable  the  nurse  should  devote  her  at- 
tention to  the  child.  It  should  first  be  anointed  with  vaseline  or  olive 
oil.  and  then  placed  in  a  warm  bath  and  thoroughly  washed  with  Castile 
soap.  Experience  has  shown  that  the  vernix  caseosa  is  much  more  readily 
removed  when  some  oleaginous  substance  is  first  employed  than  by  the  use 
of  soap  and  water  alone.  After  the  bath,  the  stump  of  the  cord  should 
be  thickly  sprinkled  with  powdered  boric  acid  and  covered  with  a  pad  of 


316  OBSTETRICS 

sterile  absorbent  cotton,  which  should  be  held  in  place  by  a  flannel  band- 
age tightly  pinned  about  the  abdomen.  If  the  child  is  doing  well  this 
dressing  need  not  be  changed  for  some  days  unless  it  becomes  moist  or 
soiled.  On  removing  it,  the  cord  will  usually  be  found  to  have  become 
completely  sejDarated,  otherwise  a  similar  dressing  should  be  reapplied. 
I  have  obtained  very  satisfactory  results  with  this  method  of  treatment, 
although  in  some  cases  it  appears  to  prolong  unduly  the  separation  of  the 
cord. 

After  the  cord  has  sloughed  off  the  granulating  umbilicus  should  be 
treated  in  the  same  manner,  and  the  child  should  not  receive  another 
full  bath  until  it  has  completely  healed.  During  this  period  it  should  be 
bathed  in  the  lap  of  the  nurse  and  not  in  a  tub,  care  being  taken  not  to 
contaminate  the  umbilical  dressings. 

In  the  winter  of  1900  Dr.  W.  M.  Dabney,  one  of  my  assistants,  per- 
formed a  series  of  experiments  in  the  hope  of  determining  the  best -meth- 
od of  dealing  with  the  cord.  He  treated  several  series  of  cases,  respec- 
tively, with  the  following  dressings:  boric  acid,  salicylic  acid,  a  mixture  of 
salicylic  acid  and  starch,  and  a  wrapping  of  silver  foil.  So  far  as  he  could 
see  it  made  no  difference  which  method  was  employed,  provided  the  dress- 
ings were  sterile.  In  still  another  series  of  cases,  he  applied  an  occlusive 
dressing  of  liquid  celloidin  and  absorbent  cotton,  but  found  that  under 
such  circumstances  the  cord  was  kept  unduly  moist,  and  separation  was 
perceptibly  delayed. 

During  the  past  few  years  this  question  has  given  rise  to  a  great  deal 
of  discussion.  Dickinson,  at  the  meeting  of  the  American  Gynecological 
Society  in  1899,  read  a  paper  entitled,  Is  the  Sloughing  Process  at  the 
Child's  Navel  consistent  with  Asepsis  in  Child-bed?  and  answered  the 
question  in  the  negative.  As  the  result  of  his  observations,  he  recom- 
mended that  the  cord  be  completely  excised  where  it  joins  the  abdomen, 
its  vessels  ligated,  and  the  wound  closed  by  sutures.  Possibly  this  may 
be  the  ideal  method  of  treatment  in  hospital  practice,  but  it  is  a  ques- 
tion whether  it  is  advisable  to  adopt  it  as  yet  in  private  practice,  as  it 
is  probable  that,  should  the  child  die  within  a  few  weeks  after  such  a 
procedure,  the  physician  would  be  severely  criticised  by  members  of  the 
family  who  have  become  accustomed  to  the  time-honoured  treatment. 

In  1900  Martin  recommended  that  the  cord  be  ligated  close  to  the  ab- 
domen and  cut  through  with  a  pair  of  red-hot  scissors.  But  although  his 
student,  Eeick,  reported  very  excellent  results  from  this  method  of  treat- 
ment, Martin  himself  has  since  abandoned  it.  Porak  and  others  advocate 
compression  of  the  cord  by  powerful  forceps,  as  in  the  recently  introduced 
methods  of  angiotripsy.  But  to  my  mind  these  procedures  offer  no  advan- 
tages over  those  already  in  use;  the  important  point  in  the  treatment 
being  not  so  much  the  method  employed  as  the  avoidance  of  infection  by 
the  most  rigid  adherence  to  the  principles  of  asepsis. 

Care  of  the  Eyes. — In  view  of  the  frequency  with  which  the  eyes  of 
the  newly  born  child  become  infected  when  passing  through  the  birth 
canal  of  women  suffering  from  gonorrhoea,  Crede  introduced  the  practice 
of  instilling  into  each  eye  immediately  after  birth  one  drop  of  a  1-per-cent 


THE   NEWLY    BORN   CHILD  317 

solution  of  nitrate  of  silver,  which  was  afterward  washed  out  with  salt 
solution.  This  procedure  lias  led  to  a  marked  decrease  in  tin-  frequency 
of  gonorrheal  ophthalmia  and  the  eases  of  blindness  resulting  from  it, 

and  should  be  followed  as  a  matter  of  routine  in  Lying-in  hospitals.  In 
private  practice,  on  the  other  hand,  a  horic-acid  solution  should  he  em- 
ployed instead,  although  if  there  is  any  reason  for  believing  that  the 
mother  has  goiioninea,  ('rede's  method  should  he  followed. 

The  prophylactic  value  of  silver  nitrate  was  strikingly  demonstrated 
by  I laah,  whose  statistics  showed  that  its  employment  in  hospital  prac- 
tice reduced  the  frequency  of  ophthalmia  neonatorum  from  9  to  1  per 
cent.  If,  however,  the  disease  should  appear  in  spite  of  the  precautions 
taken,  it  should  he  promptly  and  vigorously  treated,  inasmuch  as  when 
neglected  it  almost  invariably  leads  to  clouding  of  the  cornea  and  often 
to  complete  blindness.  Cohn  estimated  in  1876  that  30  per  cent  of  the 
patients  in  the  blind  asylums  of  Germany,  Austria,  Holland,  and  Switzer- 
land owed  their  trouble  to  ophthalmia  neonatorum,  while  twenty  years 
later  these  figures  had  become  reduced  to  19  per  cent. 

Zweifel  has  recently  advocated  substituting  a  1-per-cent  solution  of 
silver  acetate  for  the  nitrate,  and  reports  that,  in  a  series  of  5,222  children 
so  treated,  ophthalmia  was  observed  in  only  0.23  of  1  per  cent,  and  that 
not  a  single  case  ended  in  blindness. 

Stools  and  Urine. — For  the  first  few  days  after  birth  the  intestinal  con- 
tents are  represented  by  a  brownish  or  brownish-green,  soft  material — the 
meconium.  It  is  made  up  of  cast-off  epithelial  cells  from  various  portions 
of  the  intestinal  tract,  a  few  epidermal  cells  and  lanugo  hairs  which  have 
been  swallowed  with  the  amniotic  fluid.  Its  peculiar  colour  is  due  to  the 
presence  of  bile  pigments.  During  pregnancy  and  for  a  few  hours  after 
birth,  the  intestinal  contents  are  sterile,  but  bacteria  soon  gain  access  to 
them  and  are  afterward  present  throughout  life. 

After  the  third  or  fourth  clay,  with  the  establishment  of  the  mammary 
secretion,  the  meconium  disappears,  and  its  place  is  taken  by  faeces, 
which  are  light  yellow  in  colour,  homogeneous  in  consistence,  and  pos- 
sess a  characteristic  odour.  For  the  first  few  days  the  stools  are  not 
formed,  but  after  a  short  time  they  take  on  the  characteristic  cylindrical 
shape.  The  bowels,  as  a  rule,  move  twice  daily,  but  a  single  large  dejection 
is  sufficient. 

The  child  usually  urinates  almost  immediately  after  birth,  and  con- 
tinues to  do  so  at  frequent  intervals  for  the  first  few  months  of  its  life. 
The  physician  should  impress  upon  mother  and  nurse  the  necessity  of  at- 
tempting to  train  the  child  to  regular  habits  as  to  urination  and  defeca- 
tion, and  it  is  surprising  how. soon  these  may  be  formed  if  proper  care  is 
taken.  For  this  purpose  the  napkins  should  be  changed  before  each  feed- 
ing, and  after  the  first  few  weeks  the  child  should  be  held  over  a  small 
chamber  at  these  times.  It  should  also  be  encouraged  to  defecate  at 
regular  intervals.  To  accomplish  this,  it  should  be  laid  upon  the  bed  at 
the  same  hour  each  day  with  a  napkin  under  its  buttocks,  and  its  abdo- 
men should  be  stroked  along  the  course  of  the  colon.  The  physician 
should  make  it  a  rule  to  inspect  the  stools  at  each  visit,  and  instruct  the 


318 


OBSTETRICS 


nurse  to  save  a  napkin  in  anticipation  of  his  arrival,  as  in  this  way  im- 
portant information  may  be  gained  concerning. the  digestion  of  the  child. 

Icterus. — Not  infrequently  on  the  third  or  fourth  day  after  birth  the 
skin  and  conjunctivae  of  the  child  take  on  a  yellowish  hue,  which  may 
vary  from  a  hardly  visible  discoloration  to  an  intense  jaundice.  Kehrer 
concluded  that  icterus  occurred  in  75  per  cent  of  all  children,  and  al- 
though this  estimate  is  probably  too  high,  there  is  no  doubt  that  it  is 
very  common.  According  to  Hofmeier,  the  condition  is  haematogenous  in 
origin,  and  is  due  to  the  breaking-down  of  large  numbers  of  red  corpuscles 
soon  after  birth.  Ordinarily  it  possesses  no  clinical  significance,  "ancT 
passes  off  in  a  few  days  without  treatment. 

Initial  Loss  of  Weight. — Owing  to  the  fact  that  the  child  receives  little 
or  no  nutriment,  and  at  the  same  time  casts  off  considerable  quantities  of 
urine,  faeces,  and  sweat,  it  progressively  loses  weight  for  the  first  four  or 
five  days  of  its  life,  the  total  loss  usually  aggregating  250  grammes  (8 
ounces).  If  the  child  is  nourished  properly,  this  is  usually  regained  by  the 
end  of  the  tenth  day,  after  which  the  weight  should  increase  steadily  at  the 
rate  of  about  25  grammes  (6  drams)  a  day  for  the  first  few  months. 

The  initial  loss  is  usually  much  greater  when  the  child  is  excessively 
large,  as  well  as  in  premature  infants  and  those  who  receive  an  insuf- 
ficient supply  of  food. 

Anatomy  of  the  Breasts  and  Lactation. — Each  breast  is  made  up  of  from 
15  to  24  lobes,  which  are  arranged  more  or  less  radially,  and  separated 
from  one  another  by  a  varying  amount  of  fat,  to"  which  the  size  and  shape 
of  the  organ  is  in  great  part  due.  Each  lobe  consists  of  several  lobules, 
which  in  turn  are  made  up  of  large  numbers  of  acini.  These  last  are 
composed  of  a  single  layer  of  epithelium,  beneath  which  is  a  small  amount  of 
connective  tissue  richly  supplied  with  capillaries.    Every  lobule  is  provided 

with  a  small  duct, 
which,  meeting  oth- 
ers, unites  to  form  a 
single  larger  canal  for 
each  lobe.  These  so- 
called  lactiferous  ducts 
make  their  way  to  the 
nipple  and  open  sepa- 
rately upon  its  sur- 
face, where  they  may 
be  distinguished  as  mi- 
nute isolated  orifices. 

The  acini  represent 
the    functioning    por- 
tion of  the  breasts,  and  it  is  from  their  epithelium  that  the  various  constitu- 
ents Of  the  milk  are  formed.     This  fact  was  first  demonstrated  by  Hei- 
denhain. 

We  have  already  referred  to  the  changes  occurring  in  the  breasts  dur- 
ing pregnancy,  and  their  condition  remains  much  the  same  for  the  first 
two  days  after  labour.    At  this  time  they  do  not  contain  milk,  but  a  small 


Fig. 


305. — Lactating  Breast  (Zeiss,  DD-4). 


THE   NEWLY    BORN   CHILD 


319 


amount  of  colostrum  can  be  expressed  from  the  nipples.  This  is  a  thin, 
yellowish  fluid,  which  owe-  its  colour  to  the  presence  of  a  pigment  which 
is  soluble  in  ether  and,  according  to  Kiilim-.  analogous  to  the  colouring 
matter  contained  in  the  cells  of  the  corpus  luteum. 

When  examined  under  the  microscope,  colostrum  is  seen  to  consist  of 
a  fluid  in  which  are  suspended  numerous  round  bodies,  0.001  to  0.025 
millimetres  in  diameter — the  so-called  colostrum  corpuscles — which  repre- 
sent cast-off  epithelial  cells  which  have  undergone  fatty  degeneration. 
The  fluid  portion  is  a  transudate  which  consists  in  great  part  of  serum 


*&$&&* 


*9°  _  or. 


y'o  i 


o?v    °3cr  ■  c  p0  g, 


00  ?:<^°  .o. 


'&<&€ 


->*  - 


Fig.  306.— Human  Colostrum  i  Zeiss,  DD-4). 


3  o°  »  <i  fc©°  ' 

o  ^ .  WM 

'  V 

Fig.  30T.— Human  Milk    Zeiss,  DD-4). 


albumin  and  coagulates  on  heating.  It  is  generally  stated  that  colostrum 
contains  more  fat,  sugar,  and  salts,  but  less  proteid  material,  than  normal 
milk.  It  possesses  but  slightly  nutritive  properties,  and  is  generally  be- 
lieved to  act  as  a  mild  cathartic,  thus  aiding  in  ridding  the  bowels  of  the 
meconium. 

Milk. — On  the  third  or  fourth  day  after  labour  and  occasionally  on  the 
second,  the  breasts  suddenly  become  larger,  firmer,  and  more  painful. 
This  indicates  the  establishment  of  the  lacteal  secretion,  and  on  pressure 
a  small  amount  of  bluish-white  fluid — the  milk — will  exude  from  the  nip- 
ples. Coincident  with  these  changes,  the  patient  experiences  more  or  less 
lassitude,  and  may  suffer  from  headache.  At  the  same  time  she  has  throb- 
bing pains  in  the  breasts,  which  may  extend  into  the  axilla?,  and  the  pulse 
becomes  slightly  accelerated.  There  is  rarely  any  elevation  of  tempera- 
ture. It  Mas  formerly  believed  that  the  establishment  of  the  milk  flow 
was  associated  with  marked  constitutional  disturbances,  which  were  re- 
garded as  manifestations  of  the  so-called  milk  fever.  As  has  already  been 
said,  a  rise  in  temperature  from  this  cause  is  very  exceptional,  and  in  the 
vast  majority  of  cases  is  indicative  of  infection. 

Mother's  milk  is  usually  bluish-white  in  colour,  though  it  sometimes 
has  a  yellowish  tinge.  It  is  slightly  alkaline  in  reaction,  aiid  has  a  specific 
gravity  of  from  1.028  to  1.034.  Under  the  microscope  it  appears  as  a 
clear  fluid  in  which  are  suspended  large  numbers  of  small  round  bodies, 
0.008  millimetres  in  diameter — the  so-called  milk  corpuscles.     These  con- 


320  OBSTETRICS 

sist  of  minute  drops  of  fat  surrounded  by  a  membrane.  Chemical  ex- 
amination shows  that  they  are  made  up  of  the  triglycerides  of  olein,  pal- 
matin,  and  stearin.  The  fluid  portion  of  the  milk  is  a  transudate,  and  con- 
sists of  proteid  material,  milk  sugar,  salts,  and  water.  Milk,  therefore, 
represents  an  emulsion  of  fine  fat  droplets  in  a  fluid  medium. 

The  proteid  material  in  milk  serum  consists  of  casein  or  caseinogen, 
which  is  a  direct  metabolic  product  of  the  mammary  epithelium,  and 
differs  from  serum  albumin  in  that  it  does  not  coagulate  on  heating.  The 
fat  and  lactose,  or  milk  sugar,  are  also  products  of  the  epithelial  cells.  The 
milk  serum  contains  a  considerable  amount  of  mineral  matter,  which, 
according  to  the  investigations  of  Eotch,  consists  principally  of  calcium 
phosphate,  28.87  per  cent,  potassium  carbonate,  23.47  per  cent,  sodium 
chloride,  21.77  per  cent,  potassium  chloride,  12.05  per  cent,  potassium 
sulphate,  8.33  per  cent,  magnesium  carbonate,  3.97  per  cent,  and  minute 
quantities  of  several  other  salts. 

The  average  composition  of  milk  is  as  follows:  Proteids,  1  to  2  per  cent; 
fats,  3  to  4  per  cent;  sugar,  6  to  7  per  cent;  salts,  0.1  to  0.2  per  cent,  the  rest 
being  water.  Milk  also  contains  a  not  inconsiderable  number  of  bacteria, 
which,  according  to  the  researches  of  Kostlin,  are  derived  from  the  terminal 
ends  of  the  lactiferous  ducts  and  the  surface  of  the  nipples;  it  is  question- 
able whether  they  are  present  in  the  deeper  portions  of  the  breast. 

Nutritious  mother's  milk  varies  markedly  in  its  composition,  not  only 
in  different  individuals,  but  also  in  the  same  individual  at  various  times. 
It  is  not  unusual  to  find  that  the  milk  of  one  woman,  which  agrees  per- 
fectly with  her  own  child,  will  prove  indigestible  when  given  to  the 
healthy  child  of  another  woman.  The  variation  in  the  composition  of  the 
milk  of  the  same  woman  at  different  times  is  dependent  upon  various 
factors,  principally  the  diet,  the  amount  of  exercise,  and  the  mental  con- 
dition. The  quantity  of  milk  varies  to  a  large  extent  with  the  amount 
of  fluid  ingested  by  the  patient,  and  a  diet  rich  in  cow's  milk  conduces  to 
increased  mammary  activity. 

There  are  large  numbers  of  preparations  in  the  market  which  are 
known  as  galactagognes,  and  are  vaunted  as  increasing  the  amount  of 
milk;  but  whatever  virtue  they  may  possess  is  due  in  great  part  to  the 
quantity  of  fluid  taken  with  them.  Exercise  in  the  open  air  also  increases 
the  milk  flow,  and  it  is  frequently  observed  that  a  woman  who  has  but  a 
small  quantity  so  long  as  she  is  confined  to  her  room,  will  secrete  an  abun- 
dant supply  as  soon  as  she  begins  to  take  outdoor  exercise. 

The  quality  of  the  milk  is  likewise  dependent  in  great  part  upon  the 
food  and  the  amount  of  exercise  taken  by  the  mother.  It  is  a  matter  of 
experience  that  a  diet  rich  in  proteids  increases  the  ratio  of  the  fats,  while 
excessive  exercise  diminishes  the  amount  of  proteid  material.  Marked 
alterations  in  the  quality  and  quantity  of  the  milk  not  infrequently  result 
from  nervous  and  mental  influences,  and  it  is  not  unusual  for  some  profound 
emotion  to  lead  to  almost  complete  suppression  of  the  lacteal  secretion,  or 
to  so  change  its  quality  as  to  render  it  unfit  for  the  use  of  the  infant. 
Certain  drugs  also  exert  a  marked  influence  upon  the  milk  flow,  and  it  is 
well  known  that  the  use  of  belladonna  or  atropine  markedly  diminishes  it. 


THE  NEWLY    BORN   CHILD  321 

Many  substances  ingested  by  the  mother  may  be  transmitted  through  the 
milk,  and  thus  exert  their  physiological  inlluence  upon  the  child.  This 
is  particularly  true  of  the  various  cathartics  and  alcoholic  liquors. 

The  occurrence  of  menstruation,  or  the  onset  of  another  pregnancy 
during  lactation,  not  infrequently  exerts  a  very  deleterious  effect  upon 
the  quality  of  the  milk,  in  some  cases  rendering  it  necessary  to  wean 
the  child.  ' 

Nursing. — The  ideal  food  for  the  newly  born  child  is  the  milk  of  its 
mother,  and  unless  lactation  be  contra-indicated  by  some  physical  defect, 
it  is  the  physician's  duty  to  insist  that  every  woman  should  at  least  at- 
tempt to  nurse  her  child.  In  many  instances  where  the  supply  of  milk 
at  first  appears  insufficient,  it  becomes  increased  in  amount  if  nursing 
be  persisted  in.  The  act  itself  usually  exerts  a  beneficial  influence  upon 
the  patient,  as  it  is  well  known  that  the  repeated  irritation  of  the  nipples 
results  in  reflex  stimulation  of  the  uterus  and  hastens  its  involution.  This 
fact  should  be  urged  upon  women  who  are  unwilling  to  nurse  their  children, 
and  it  not  infrequently  happens  that,  although  they  may  have  commenced 
it  from  selfish  motives,  they  will  continue  it  as  long  as  is  necessary. 

Unless  it  be  otherwise  arranged,  the  physician  who  conducts  the  labour 
should  hold  himself  responsible  for  the  well-being  of  the  child  during  the 
first  few  weeks  of  its  life,  and  should  remember  that  he  has  not  only  the 
mother  but  also  the  child  to  care  for.  He  should  accordingly  give  minute 
directions  as  to  the  w^ay  in  which  it  should  be  fed,  and  see  that  they  are 
accurately  carried  out. 

Frequency  of  Feeding. — As  the  nutritive  properties  of  colostrum  are 
very  limited,  the  child  should  be  put  to  the  breast  only  three  times  a  day 
until  the  milk  flow  becomes  established,  but  after  that  time  it  should  be 
fed  at  frequent  and  regular  intervals.  Definite  hours  should  be  set  for 
each  feeding,  and  if  necessary  the  child  should  be  awakened  from  a  sound 
sleep  at  stated  times  to  take  its  nourishment,  for  only  by  this  means  can 
its  habits  be  made  regular.  I  do  not  consider  that  a  nurse  has  fulfilled 
her  whole  duty  unless  she  leaves  the  patient  with  a  child  properly  trained 
in  the  matter  of  taking  its  food. 

A  definite  hour  should  be  arranged  for  the  child's  bath,  which  should 
be  taken  as  a  starting-point  in  arranging  the  schedule  for  feeding.  Ordi- 
narily the  most  convenient  time  is  between  9  and  10  a.  m.  If  the  former 
hour  be  chosen,  the  first  feeding  should  be  at  7  a.  m.,  and  the  next 
immediately  after  the  bath;  while  if  the  latter  be  chosen  the  child  should 
be  fed  at  6  and  8  a.  m.,  and  again  shortly  after  ten.  After  the  feeding 
immediately  following  the  bath  the  baby  should  be  allowed  to  sleep  as 
long  as  it  will,  which  will  usually  be  about  three  hours,  after  which  it 
should  be  given  nourishment  at  intervals  of  two  hours  until  bedtime.  By 
this  arrangement  it  will  receive  eight  or  nine  feedings  during  the  twenty- 
four  hours.  The  last  should  be  timed  for  the  usual  bedtime  of  the  parents, 
and  only  one  feeding  should  be  given  during  the  night — that  is,  between 
11  p.  m.  and  6  or  7  a.  m. — and  not  infrequently  the  child  may  be  trained 
to  sleep  the  entire  night  without  awakening.  This,  however,  can  only  be 
accomplished  by  feeding  it  at  regular  intervals  during  the  day,  so  as  to 


322  OBSTETRICS 

insure  that  it  receives  the  proper  amount  of  nutriment  in  the  twenty-four 
hours. 

Just  before  each  feeding  the  napkin  should  be  changed  and  the  child 
encouraged  to  urinate,  but  as  soon  as  it  is  taken  from  the  breast  it  should 
be  placed  in  bed  and  not  disturbed.  It  should  not  be  allowed  to  sleep 
at  its  mother's  breast,  nor  should  it  be  rocked  or  fondled  after  feeding. 
If  these  regulations  be  persisted  in,  the  child  will  usually  go  to  sleep 
within  a  few  minutes  after  being  put  to  bed,  and  if  it  wakes  before  the 
next  feeding  is  due  it  will  remain  quiet.  The  importance  of  following 
these  directions  cannot  be  overestimated,  for  it  is  only  by  rigid  adherence 
to  such  details  that  the  child  can  be  given  regular  habits,  and  the  care  of 
it  jDrevented  from  becoming  a  strain  ujDon  all  concerned. 

After  the  fourth  or  fifth  week,  one  or  two  of  the  breast  feedings 
should  be  replaced  by  a  bottle,  no  matter  how  much  milk  the  mother  may 
have.  By  so  doing  the  slavery  of  nursing  is  greatly  reduced,  and  many 
a  woman  is  induced  to  continue  to  nurse  her  child  when  she  would  otherwise 
wean  it.  When  a  mother  is  obliged  to  return  home  every  two  or  three  hours 
to  nurse  her  child,  it  is  apparent  that  her  time  is  so  broken  in  upon  as  to 
render  it  impossible  for  her  to  obtain  any  real  relaxation;  whereas  if  a 
single  bottle  be  interpolated  between  any  two  feedings  a  free  space  of 
four  to  six  hours  will  be  afforded. 

Duration  of  Feeding. — Definite  rules  cannot  be  given  concerning  the 
proper  length  of  each  feeding,  as  this  point  is  dependent  upon  several 
factors — the  quantity  of  milk,  the  readiness  with  which  it  can  be  obtained 
from  the  breast,  and  the  avidity  with  which  the  child  nurses.  Generally 
speaking,  it  is  advisable  to  allow  the  child  to  remain  at  the  breast  for  ten 
minutes  at  first,  and  to  lengthen  or  decrease  the  time  according  to  circum- 
stances, three  or  four  minutes  being  sufficient  for  some  children,  while 
fifteen  or  twenty  minutes  will  be  required  by  others.  There  is  a  universal 
tendency  towards  overfeeding,  so  that  at  first  it  is  better  to  err  in  giving 
too  little  than  too  much  milk.  Crying  is  not  always  a  symptom  of  hun- 
ger, but  much  more  frequently  indicates  that  the  baby  is  suffering  from 
indigestion,  resulting  from  an  overloaded  stomach.  A  child  which  is  re- 
ceiving the  proper  amount  of  nourishment  should  not  spit  up  its  food, 
should  increase  steadily  in  weight,  and  should  have  normal  yellow  homo- 
geneous passages.  The  occurrence  of  regurgitation,  or  the'  presence  of 
curds  in  the  stools,  is  a  sure  sign  that  it  is  being  nursed  too  long.  On 
the  other  hand,  loss  of  weight,  associated  with  normal  stools  and  the 
absence  of  regurgitation,  indicates  insufficient  feeding. 

The  child  should  be  weighed  daily,  or  at  least  twice  a  week,  upon  a 
fairly  accurate  pair  of  scales,  and  its  actions  inspected  daily  by  the  physi- 
cian. As  has  already  been  said,  it  should  regain  its  birth  Aveight  by  the 
end  of  the  tenth  day,  and  from  then  on  it  should  gain  regularly  25 
grammes  a  day,  or,  roughly  speaking,  5  ounces  a  week.  After  the  first  few 
months  the  increase  is  more  gradual,  the  average  child  doubling  its  weight 
at  the  fifth  and  trebling  it  at  the  fifteenth  month. 

Where  practicable,  if  the  child  is  doing  well,  an  analysis  of  the 
mother's  milk  should  be  made,  so  that  definite  information  may  be  at 


THE    NEWLY    BORN   CHILD  323 

hand  as  to  the  quality  of  the  food  upon  which  it  thrives,  in  case  artificial 
feeding  should  at  any  time  become  necessary. 

Care  of  the  Breasts. —  Before  and  after  each  feeding  the  nipples  should 
be  carefully  washed  with  a  boric-acid  solution,  so  as  to  avoid  the  pos- 
sibility of  bacteria  being  ground  into  them  during  the  nursing.  In  many 
cases,  particularly  if  preliminary  precautions  have  not  been  taken  to 
harden  them,  the  nipples  become  very  sore  during  the  first  few  days  of 
nursing,  and  Little  (.racks  or  fissures  appear  upon  them.  These  are  ex- 
tremely painful  to  the  mother,  and  in  some  cases  render  the  act  of  nurs- 
ing agonizing.  In  addition  to  the  suffering  which  they  cause,  they  are 
also  a  source  of  considerable  danger,  as  it  is  through  them  that  bacteria 
usually  gain  access  to  the  interior  of  the  breast.  The  nurse  should 
therefore  he  instructed  to  be  on  the  lookout  for  them,  and  to  warn  the 
physician  at  once  of  their  appearance,  as  prompt  treatment  will  usually 
lead  to  their  speedy  cure.  On  the  other  hand,  neglect  of  these  premoni- 
tory signs  is  not  infrequently  followed  by  a  mammary  abscess,  for  the  oc- 
currence of  which  the  physician  and  nurse  are  usually  more  or  less  justly 
blamed. 

The  fact  that  large  numbers  of  remedies  are  recommended  for  the  cure 
of  such  conditions  is  abundant  evidence  that  they  are  not  always  readily 
relieved.  They  are  best  treated  by  rest,  and  if  the  infant  could  be  kept 
from  the  breast  for  twenty-four  hours  they  would  heal  without  further 
treatment.  As  this  is  out  of  the  question,  some  other  means  of  securing  rest 
must  be  adopted,  and  this  is  best  attained  by  the  use  of  nipple  shields, 
those  of  the  ordinary  English  type  being  the  most  suitable.  Many  women 
claim  that  they  are  unable  to  use  such  a  contrivance,  but  the  difficulty 
is  usually  due  to  the  fact  that  the  holes  in  the  rubber  nipple  are  too 
small,  and  if  they  are  enlarged  by  passing  a  red-hot  hairpin  through 
them  a  quantity  of  milk  sufficient  for  the  child  can  usually  be  obtained 
without  much  difficulty.  In  the  intervals  between  the  feedings  the  nip- 
ples should  be  covered  by  compresses  soaked  with  boric-acid  solution. 
Particular  attention  should  be  devoted  to  the  care  of  the  shield,  which 
should  be  carefully  washed  after  each  feeding  and  kept  in  a  vessel  contain- 
ing a  saturated  solution  of  boric  acid. 

In  rare  cases  the  nipples  may  be  so  depressed  below  the  surface  of 
the  breast  as  to  render  nursing  out  of  the  question.  Under  such  circum- 
stances it  is  useless  to  attempt  it,  and  steps  should  be  promptly  taken  to 
arrest  the  mammary  secretion. 

The  child's  mouth  should  be  scrupulously  cleansed  before  each  feed- 
ing. This  is  best  accomplished  by  washing  it  out  with  a  clean  piece  of 
linen  dipped  in  boric-acid  solution.  The  recent  investigations  of  Kneise, 
which  have  shown  that  bacteria  are  present  in  the  buccal  cavity  of  98  per 
cent  of  newly  born  children,  and  that  streptococci  and  staphylococci  are 
not  infrequently  observed,  emphasize  the  necessity  for  care  in  this  di- 
rection. 

Artificial  Feeding. — When  the  supply  of  mother's  milk  is  defective, 
or  when  abnormalities  of  the  nipples  or  constitutional  diseases  render 
nursing  inadvisable,  artificial  feeding  must  be  resorted  to.     Numerous  so- 


324  OBSTETRICS 

called  infant  foods  are  advertised  for  this  purpose,  but  most  of  them  are 
yerv  defective,  so  that  for  practical  purposes  cow's  milk  in  some  form 
is  the  only  available  substitute  for  the  mother's  milk.  Unfortunately, 
however,  it  differs  markedly  from  the  latter  in  composition,  and  under 
the  most  favourable  circumstances  is  only  an  imperfect  substitute  for  it. 
It  is  usually  slightly  acid  in  reaction,  and  has  a  specific  gravity  of  1.029 
to  1.033.  Its  average  composition  is:  proteids,  4  per  cent,  fats,  1  per  cent, 
sugar,  4.5  per  cent,  and  salts,  0.7  per  cent.  It  is  apparent,  therefore,  that 
it  contains  less  fat  and  sugar,  and  more  proteid  material  and  salts  than 
mother's  milk,  and  consequently  cannot  be  used  in  its  natural  form,  but 
must  first  be  modified  in  some  way. 

If  the  child  is  healthy,  satisfactory  results  are  frequently  obtained 
by  diluting  cow's  milk  with  various  proportions  of  water  and  adding  sugar. 
Such  preparations  contain  approximately  the  normal  amount  of  proteid 
material  and  sugar,  but  are  lacking  in  fat.  In  hot  weather  the  mixture 
should  be  sterilized,  but  in  cool  weather  this  procedure  is  unnecessary. 

Modified  milJc,  in  which  the  various  constituents  of  cow's  milk  can  be 
altered  at  will,  so  that  theoretically,  at  least,  it  closely  approximates  mother's 
milk  in  composition,  promised  to  supply  us  with  an  ideal  artificial  food, 
and  in  many  respects  is  the  best  substitute  for  breast  milk.  But  at  the 
same  time  it  differs  from  it  in  the  fact  that  its  proteid  material  is  far  less 
digestible,  and,  when  coagulated  by  the  gastric  juice,  forms  a  thick,  dense 
coagulum,  contrasting  unfavourably  with  the  fine  curd  formed  from  human 
milk.  In  employing  it,  therefore,  smaller  quantities  of  proteid  material 
must  be  prescribed  than  are  normally  present  in  breast  milk. 

The  space  at  our  disposal  is  too  limited  to  permit  us  to  take  up  the 
many  and  complicated  problems  connected  with  artificial  feeding.  For 
extended  information  upon  this  subject  the  reader  is  referred  to  the 
various  treatises  upon  Paediatrics.  There  are,  nevertheless,  two  points  to 
which  we  must  refer — namely,  the"  capacity  of  the  stomach  and  the  neces- 
sity for  training  the  child  to  regular  habits,  no  matter  what  method  of 
feeding  is  employed.  It  should  be  remembered  that  the  stomach  of  the 
newly  born  child  is  very  small,  and  that  1  ounce  will  fill  it  to  repletion 
for  the  first  few  days  after  birth.  That  amount  of  fluid,  therefore,  should 
not  be  exceeded  for  the  first  few  days,  after  which  it  should  be  increased 
very  gradually.  The  instructions  as  to  the  frequency  and  manner  of  feed- 
ing, which  we  have  already  given,  apply  equally  well  whether  the  child  is 
fed  from  the  breast  or  the  bottle,  and  too  great  stress  cannot  be  laid  upon 
their  rigid  observance. 

LITERATURE 

Ahlfeld.     Lehrbuch  der  Creburtshiilfe.  II.  Aufl..  1897.  179. 

Conx.  Ueber  Yerbreitung  und  Yerhiitung  der  Augeneiterung  der  Neugeborenep.  Berlin. 
1896. 

Crede.     Die  Verlmtung  der  Augenentzundung  beim  Xeugeborenen.     Berlin.  1884. 

Dickinson.  Is  a  Sloughing  Process  at  the  Child's  Xavel  Consistent  with  Asepsis  in  Child- 
bed?   Amer.  Jour.  Obst..  1899.  xl.  14-66. 

Eross.  Beobachtung-en  an  1000  Xeugeborenen  uber  Xabelerkrankungen.  etc.  Archir  f. 
Gyn.,  1891,  xli,  409-449. 


THE   NEWLY    BORN   CHILD  325 

IIaab.    Die  Mikrokokken  der  Blenorrhoea  neonatorum.    Festschrift  zu  Horner,  Wies- 
baden, 1881. 
Hofmeies.     DieGelbsuchl  der  Neugeborenen.    Zeitschr.  r.  Geb.u. Gyn.,  1882,  \  iii.  287-853. 
Kehbee.    Studien  liber  den  Icterus  neonatorum.    Jahrbucb  fllr  Padiatrik,  1*71.  ii,  71. 
Kneise.    Die  Bakterienflora  der  MundhOhle  des  Neugeborenen,  etc.    Hegar's  Beitragi  f. 

Geb.u.  Ciyii.,  L901,  i\.  L30-1  18. 
KOstlix.    Beit  rage  zur  Frage  des  Keimgehaltes  der  Frauenmilch.     Archiv  f.  Gyn.,  1897, 

liii,  201-0;;. 
Martin.     Die  V"ersorgung  des  Nabels  der  Neugeborenen.    Zeitschr.  f.  Geb.  u.  Gyn.,  1000, 

42,  593-596. 
Zur  Nabelschnurversorgung  bei  Neugeborenen.     Monatssehr.  f.  Geb.  u  Gyn.,  1000,  xii, 

762-763. 
Ploss.     Das  Weib  in  der  Natur-  and  Volker-kunde.    IV.  AufL,  1895,  Bd.  II,  182-198. 
Porak.     De  l'omphatotripsie.     Annales  de  Gyn.  et  d'Obst.,  1900,  liv,  112-113. 
Rieck.    Die  Versorgung  des  Nabels  der  Neugeborenen.     Monatssehr.  f.  Geb.  u.  Gyn.. 

1900.  xi,  918-933. 
Strassmann.     Anat.  u.  physiol.  Untersuchungen  liber  den  Blutkreislauf  beim  Xeuge- 

borenen.    Archiv  f.  Gyn.,  1894,  xlv,  393-445. 
Der  Verschluss  des  Ductus  arteriosus.     Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1902,  vi, 

98-117. 
Zweifel.     Die  Verhiitung  der  Augeneiterung  Neugeborenen.     Centralbl.  f.  Gyn.,  1900, 

1361-1380. 


CHAPTER  XVIII 
MULTIPLE  PREGNANCY 

The  uterus  occasionally  contains  two  or  more  embryos;  thus,  accord- 
ing to  the  number  present  we  have  a  twin,  triplet,  quadruplet,  or  quintuplet 
pregnancy. 

Vassalli  has  recorded  the  only  credible  instance  of  sextuplet  preg- 
nancy, but  even  his  case  has  been  subjected  to  considerable  criticism.  On 
the  whole,  it  may  be  said  that  reports  of  the  birth  of  more  than  six  chil- 
dren at  a  single  labour  are  to  be  regarded  as  apocryphal,  although  many 
such  are  to  be  found  in  the  older  literature,  the  most  remarkable  being 
the  Rhine  legend,  according  to  which  the  Countess  Hagenau  was  delivered 
of  365  embryos  at  a  single  labour — manifestly  an  hydatidiform  mole. 

Frequency. — Wappaeus  found  that  more  than  one  child  was  born  in 
1.17  per  cent  of  20,000,000  cases  of  labour  which  he  analyzed.  The  sta- 
tistics of  G.  Veit,  which  were  based  upon  13,000,000  cases  occurring  in 
Prussia,  showed  that  twins  occurred  once  in  89,  triplets  once  in  7,910,  and 
quadruplets  once  in  371,125  labours.  According  to  Mirabeau,  triplets  oc- 
cur more  frequently — once  in  6,500  cases. 

It  would  appear  that  multiple  pregnancy  is  more  common  in  cold  than 
in  warm  climates.  -This  statement  is  borne  out  by  the  statistics  of  Ber- 
tillon  and  Mirabeau,  the  latter  stating  that  they  occur  once  in  41.8 
labours  in  Russia,  as  compared  with  once  in  113.6  labours  in  Spain.  Ac- 
cording to  Duncan,  twin  pregnancy  is  noted  most  frequently  in  multip- 
ara?, especially  between  the  twenty-fifth  and  twenty-ninth  years. 

It  has  been  estimated  that  in  64  per  cent  of  the  cases  only  one,  and 
in  36  per  cent  both  sexes  are  represented.  Thus  Pinard,  in  150  observa- 
tions, found  that  both  children  were  males  in  46,  females  in  46,  and  of 
different  sexes  in  58  cases. 

2Etiology. — Certain  individuals  appear  to  be  predisposed  towards  mul- 
tiple pregnancy,  since  it  is  not  unusual  for  the  same  woman  to  give  birth 
to  twins  or  triplets  upon  several  occasions.  Thus  Peuch,  upon  analyzing 
1,262  cases  of  twin  pregnancy,  found  that  48  of  the  mothers  had  had  twins 
twice,  3  thrice,  and  1  upon  4  occasions.  In  some  instances  multiple  preg- 
nancy has  been  known  to  occur  in  all  the  females  of  a  family  throughout 
several  generations.  Mirabeau  has  pointed  out  that  an  hereditary  tendency 
towards  triplet  pregnancies  was  recorded  in  13  out  of  the  75  cases  col- 
lected by  him.  This  was  particularly  marked  in  one  family,  in  which  trip- 
326 


MULTIPLE   PREGNANCY 


■  •■11 


lets,  not  to  mention  twins,  had  occurred  one  or  more  times  in  five  succes- 
sive generations. 

In  rare  instances,  however,  this  tendency  appears  to  come  through 
the  father,  and  reference  is  frequently  made  to  the  somewhat  apocryphal 
case  of  the  Russian  peasant,  Wasilef,  who  had  87  children  by  2  wives, 
the  lirsi  having  had  I  quadruplet,  1  triplet,  and  L6  twin  pregnancies;  and 
the  second  '!  triplet  and  (i  twin  pregnancies. 

According  to  Hellin,  Patellani,  and  Larger,  multiple  pregnancy  should 
be  regarded  as  a  sign  of  degeneration,  and  represents  an  atavistic  rever- 
sion.  The  first-mentioned  authority  states  that  the  ovaries  of  women 
who  have  had  a  number  of  multiple  pregnancies  contain  an  excessive 
number  of  ova,  but  that  individual  ova  with  double  nuclei  are  very  rarely 
noted.  According  to  this  view,  the  condition  is  probably  due  to  the 
maturation  each  month  of  several  ova,  instead  of  one,  as  is  generally  the 
rule. 

Twin  pregnancy  may  result  either  from  the  fertilization  of  two  sepa-, 
rate  ova  or  of  a  single. ovum,  the  first  giving  rise  to   double,   and  the 
second  to  single  ovum  twins.    In  the  former  case,  the  ova  may  come  from 
the  same  ovary,  or  one  from  each  ovary;  while 
in  rare  instances  both  may  originate  in  a  single 
follicle.     In  the  latter,  the  ovum  may  present 
two  distinct  germinal  vesicles,  each  of  which  be- 
comes  converted  into  a  female  pronucleus  and 
undergoes  fertilization;  or  the  twins  may  result 
from  the  cleavage  or  division  of  a  single  embi^- 
onic  area,  or  from  double  gastrulazation  _of  the 
blastodermic,  vpsicle     Saniter  states  that  in  trip- 


WM 
'■MM 


:  /0^ 


Fig.  308. — Ovum  with  Double- 
Germinal  Vesicle. 


let  pregnane}'-  the  children  are  usually  derived 
from  two  ova — one  from  one  and  two  from  the 
other — while  in  rare  cases,  one  of  which  he  has 
studied  personally,  all  three  children  are  derived 
from  a  single  ovum. 

The  existence  of  ova  with  double  nuclei  is 
indisputable,  Franque,  Herff,  Klien,  and  others 
having  reported  undoubted  examples  of  such  a 
condition.  Fig.  308  represents  an  ovum  of  this  character  observed  by  the 
author.  Whether,  however,  single  ovum  twins  are  derived  from  such  ova, 
or  whether  they  are  due  to  cleavage  of  an  ordinary  blastodermic  vesicle, 
are  questions  that  as  yet  have  not  been  decided,  and  whose  solution  offers 
great  difficulties.  Years  ago  Ahlfeld  advanced  the  latter  view,  which  has 
lately  (1901)  been  revived  by  Sobotta. 

It  is  well  known  that  cleavage  of  the  embryonic  are^i  can  be  produced 
experimentally  in  many  of  the  lower  animals,  and  Ahlfeld  and  Sobotta 
believe  that  similar  changes  may  occur  in  human  beings.  According  to 
this  view,  single-ovum  twins  are  closely  related  to  the  so-called  doubly 
monsters.  Sobotta  is  inclined  to  believe  that  this  is  the  only  mode  of 
origin  of  this  class  of  twins,  as  he  considers  it  impossible  for  two  sper- 
matozoa to  enter  the  same  ovum  and  unite  with  two  female  pronuclei. 


323 


OBSTETRICS 


Of  1,159  instances  of  twin  pregnancy  analyzed  by  Ahlfeld,  977  were 
derived  from  two  ova  and  180  from  a  single  ovum.  In  the  former  case 
the  children  may  or  may  not  be  of  the  same  sex,  while  in  the  latter  they 
are  always  of  the  same  sex,  and  often  closely  resemble  one  another. 

Relation  of  Placenta  and  Membranes.- — The  examination  of  the  placenta 
and  fcetal  membranes  after  labour  usually  enables  one  to  determine  the 
mode  of  origin  of  the  twins.  When  they  are  derived  from  a  single  ovum 
there  is  a  single  large  placenta  from  which  the  two  umbilical  cords  come 
off;  but  when  they  are  developed  from  two  ova  there  are  usually  two 
separate  placentae,  although  occasionally,  when  these  were  originally  insert- 

jed  near  one  another,  their  contiguous  edges  may  fuse  together,  thus  giving 

/rise  to  an  apparently  single  large  placenta,  in  which,  however,  there  is  no 

I  connection  between  the  circulation  of  the  two  twins. 

In  double-ovum  twins,  no  matter  whether  the  placenta;  are  separate  or 
fused  together,  there  are  two  chorions  and  two  amnions,  each  child  being 
enveloped  in  its  own  membranes"    Snlgle-ovum  twins  possess  only' a  single 

i  chorion,  but,  as  a  rule,  two  amnions,  for  the  reason  that  the  former  repre- 
sents the  wall  of  the  origrnd^nastodermic  vesicle,  while  the  amnion  is 
more   directly   connected  with   the   embryo   itself.      In   rare   instances   a 

\ 


Fig.  309. — Placenta,  Double-Ovum  Twins,  Velamentous  Insertion  of  Cord. 

single  amnion  is  found.  This  condition,  which  was  noted  in  3  of  Ahl- 
feld's  1,157  cases,  is  not  primary,  but  results  from  perforation  of  the  parti- 
tion wall  between  the  two  original  amniotic  cavities. 

This  arrangement  of  the  membranes  was  known  to  A7iardel  in  the 
seventeenth  century,  who  stated  that  when  the  children  were  of  the  same 
sex  they  were  usually  inclosed  in  a  single  amnion;  whereas  twins  of  different 
sexes  were  separated  by  a  partition  wall.     He  expressed  the  belief  that 


multii'LI-:  imm-:«;n.\.\(  v 


:)-2'.\ 


Providence  took  this  means  of  guarding  their  morals  in  utero.  Saniter 
( l'.nii ).  in  a  very  interesting  article,  bas  can  ■fully  studied  the  relation  of  the 
fcetal  membranes  in  t  riplel  pregnancy. 

In  single-ovum  twins  there  is  always  a  en-tain  area  of  the  placenta  in 
which  there  is  ajiastomosis  between  the  two  vascular  systems,  which  is 
never  present  in  the  fused  placenta  of 
double-ovum  twins.  This  condition  bas 
been  exhaustively  studied  by  Schatz,  and 
occasionally  leads  to  serious  consequences. 
Thus,  if  at  an  early  period  the  heart  of 
one  embryo  i-  considerably  stronger  than 
that  of  the  other,  a  gradually  increasing 
area  of  the  communicating  portion  of  the 
placenta  is  monopolized  by  the  former,  so 
that  its  heart  increases  rapidly  in  size, 
while  that  of  the  latter  receives  less 
and  less  blood  and  eventually  atrophies. 
Herein  is  to  he  found  the  explanation 
of  the  deformity  known  as  acardia.  In 
such  eases  almost  the  entire  placental  cir- 
culation is  utilized  by  the  normal  embryo, 
while  the  deformed  twin  receives  only 
enough  blood  to  nourish  its  lower  ex- 
tremities. 

Xot  infrequently  a  difference  in  the 
strength  of  the  two  hearts  leads  to  the 
production  of  hydramnios  in  one  ovum. 
In  such  cases  it  is  believed  that  the 
stronger  heart  appropriates  an  ever-in- 
creasing share  of  the  blood  from  the  pla- 
centa and  undergoes  hypertrophy,  which 
is  followed  by  an  abnormal  urinary  secra- 
tion_ and  a  consequent  increase  in  the 
quantity  of  amniotic  fluid. 

In  the  rare  instances  in  which  single- 
ovum  twins  are  inclosed  in  a  common  am- 
nion, their  umbilical  cords  may  become  so 
twisted  about  one  another  as  to  interfere 
with  the  circulation  through  them,  and 
thus  lead  to  death  and  an  early  termina- 
tion of  pregnancy.  Hermann,  in  1891, 
collected  16  such  cases  from  the  liter- 
ature. 

Ordinarily  in  double-ovum  twin  preg- 
nancies   each    ovum    occupies,    roughly 

speaking,  one  half  of  the  uterus,  the  long  axis  being  directed  vertically. 
Occasionally,  however,  they  run  transversely,  so  that  one  fcetal  sac  comes 
to  lie  above  the  other.    Under  such  circumstances  the  placenta  and  mem- 


^ 


Fig.  310. — Diagram  shotvixg  Relation 
of  Placenta  axd  Membranes  in 
Double-  axd  Single -Ovum  Twin 
Pregnancy. 

a.,  double  -  ovum  twins:  b..  double  -ovum 
twins,  double  membranes,  single  pla- 
centa ;  c,  single-ovum  twins,  one  cho- 
rion, two  amnions,  and  one  placenta. 


330 


OBSTETRICS 


Fig.  311. 


branes  of  the  first  child  must  be  expelled  from  the  uterus  before  the  second 
child  can  be  born,  unless  the  latter  can  make  its  way  past  them. 

Size  of  Children. — Generally  speaking, 
twins  are  smaller  and  weigh  less  than  chil- 
dren resulting  from  simple  pregnancies, 
although  their  combined  weight  is  usually 
greater  than  that  of  a  single  child.  The 
smaller  size  may  be  considered  normal,  but 
in  some  instances  is  partially  to  be  ex- 
plained by  the  fact  that  the  excessive  dis- 
tention of  the  uterus  tends,  more  or  less, 
to  premature  labour,  so  that  the  twins  are 
often  born  several  weeks  before  maturity. 
According  to  Eibemont-Dessaignes  this 
occurs  in  83  per  cent  of  primiparae  and  75 
per  cent  of  multipara. 

It  is  not  unusual  for  twins  to  differ 
considerably  in  size  and  weight,  especially 
when  derived  from  a  single  ovum.  Ahlf eld 
has  reported  three  eases  in  which  the  twins 
weighed,  respectively,  2,320  and  1,120, 
2,700  and  1,650,  and  1,920  and  790 
grammes. 

In  double-ovum  twin  jDregnancy  it  is 
not  unusual  for  one  child  to  die  at  an  early 
period  and  be  expelled  from  the  uterus 
soon  afterward,  while  the  other  may  go  on 
to  full  development.  More  frequently, 
however,  the  lead  foetus  is  retained  until 
the  end  of  pregnancy,  and  becomes  flat- 
tened out  and  partially  mummified,  being 
compressed  between  the  uterine  wall  and 
the  membranes  of  the  living  child — foetus 
pamirnr.p.iis  or  compressus  (Fig.  314). 

Super  fecundation  and  Superfcetation. — 
The  consideration  of  the  difference  in  the 
weight  of  twins,  and  the  possibility  of  one 
being  aborted  while  the  other  develops 
until  full  term,  leads  up  to  the  question  of 
superfecundation  and  superfcetation.  By 
the  former  we  understand  the  fertilization 
of  two  ova  within  a  short  period  of  one 
another,  but  not  at  the  same  coitus;  where- 
as in  the  latter  several  months  may  inter- 
vene. 

Superfecundation  is  a  well-recognised 
occurrence  in  the  lower  animals,  and  undoubtedly  occurs  in  human  be- 
ings, although  it  is  impossible  to  determine  its  frequency.     It  is  prob- 


Fig.  312. 


Fig.  313. 

Figs.  311-313. — Diagrams  showing  P-osi 

tion  of  Twins  in  Utero. 


MULTIPLE    PREGNANCY 


331 


able  that  in  many  cases  the  two  ova  are  not  fertilized  at  the  same  coitus, 
but  this  can  be  demonstrated  only  under  exceptional  circumstances.  In 
a  case  observed  at  the  Lariboisiere,  in  Paris,  the  woman  had  had  connec- 
tion with  a  white  and  a  coloured  man  respectively  within  a  shorl  period, 
ami  was  delivered  of  twin-,  one  of  which  was  white  and  the  other  a 
mulatto.  At  the  Johns  Eopkins  Hospital  a  coloured  woman  gave  birth 
to  twins,  one  being  born  dead  ami  th<  other  perfectly  healthy.  Dis- 
tinct cviil.-n.Mv--  of  syphilis  were  present  in  the  first  child  ami  its  placenta, 
while  the  second  remained  perfectly  well  some  months  after  it-  delivery. 
On  questioning  the  patient  it  was  ascertained  that  she  had  had  connection 
with  her  hushand  and  another  man  within  a  period  of  a  few  days,  ami  that 
the  former  was  under  treatment  for  syphilis  at  the  time. 

The  occurrence  of  superfcetation  has  never  yet  been  clearly  demon- 
strated, though  its  theoretical  possibility  must  be  admitted.  Generally 
speaking,  the  uterine  cavity  does  not  become  completely  obliterated  until 
the  decidua  reflexa  and  vera  fuse  together  at  the  end  of  the  third  month  of 
pregnancy,  atter  winch 
supericetation  is  out  of 
the  question;  but  prior 
to  that  period  there  is 
no  theoretical  objection 
to  supposing  that,  if 
ovulation  should  occur, 
an  ovum  might  find  its 
way  into  the  uterine 
cavity  and  there  be 
fertilized.  Still  more 
favourable  conditions 
would  be  afforded  by 
a  uterus  duplex. 

The  French  author- 
ities consider  that  such 
an  event  has  been  con- 
clusively demonstrated, 
and  many  of  the  argu- 
ments which  have  been 
advanced  in  its  favour 

are  given  by  Tarnier.  On  the  other  hand,  most  English  and  German  au- 
thors are  somewhat  sceptical,  and,  while  admitting  its  theoretical  possi- 
bility, believe  that  the  majority  of  instances  put  under  this  category,  have 
been  due  either  to  the  abortion  of  one  twin  or  to  marked  inequality  of 
development. 

Diagnosis. — It  often  happens  that  the  presence  of  twins  in  the  uterus 
is  unsuspected  during  pregnancy,  and  the  first  intimation  which  the  physi- 
cian has  of  the  true  condition  is  afforded  by  the  unusually  large  size  of  the 
uterus  after  the  expulsion  of  the  first  child.  Despite  this  fact,  however, 
it  may  be  said  that  such  surprises  will  rarely  occur  in  the  practice  of  those 
who  take  the  trouble  to  make  a  thorough  preliminary  examination. 


Fig.  314. — Fcetus  Paptbaceus  i  Eibemont-Dessaignes)j 


332  OBSTETRICS 

Excessive  size  of  the  abdomen  during  pregnancy  frequently  causes 
one  to  suspect  the  presence  of  twins,  though  usually  it  will  he  found  to 
be  due  to  some  other  condition.  Thus,  owing  to  the  marked  relaxation 
of  the  abdominal  walls  following  the  birth  of  the  first  child,  women  preg- 
nant for  a  second  time  often  think  that  they  will  give  birth  to  twins, 
although,  as  a  matter  of  fact,  their  fears  are  generally  without  foundation. 

The  diagnostic  means  at  our  disposal  are  palpation,  auscultation,  and 
touch.  If  a  multiplicity  of  small  parts  is  encountered  on  palpation,  the 
possibility  of  a  twin  pregnancy  should  always  be  suspected  and  a  further 
examination  made  with  especial  reference  to  this  point.  Positive  evi- 
dence is  afforded  by  the  palpation  of  two  heads,  two  breeches,  and  two 
backs;  or  at  least  of  one  back  and  four  foetal  poles.  The  detection  of  three 
foetal  poles  is  not  conclusive,  for  the  reason  that  in  rare  instances  a  sub- 
peritoneal or  intramural  myoma  may  simulate  the  head  of  a  child  and  thus 
give  rise  to  serious  diagnostic  errors. 

Auscultation  occasionally  gives  most  valuable  information,  and  if  one 
can  distinguish  two  areas,  considerably  removed  from  one  another,  in 
which  a  foetal  heart  can  be  heard,  twins  should  be  suspected;  but  a  positive 
diagnosis  should  not  be  made  unless  there  is  a  difference  of  at  least  10 
beats  per  minute  in  the  rate  of  the  two  hearts,  the  sounds  being  counted 
for  at  least  a  minute  in  each  location. 

In  rare  instances  vaginal  touch  may  reveal  important  findings,  as  it 
is  sometimes  possible  to  distinguish  through  a  macerated  head  the  intact 
membranes,  or  a  prolapsed  and  pulseless  cord  may  be  felt  through  the 
cervix,  while  auscultation  gives  positive  evidence  of  the  presence  of  a 
living  child. 

The  presence  of  more  than  two  children  can  be  predicted  with  cer- 
tainty only  under  very  exceptional  and  favourable  circumstances,  although 
Eibemont-Dessaignes  reports  the  diagnosis  of  triplets  during  pregnancy 
and  its  confirmation  at  the  time  of  labour. 

Course  of  Labour. — "We  have  ralready  referred  to  the  abnormal  size 
of  the  uterus  resulting  from  the  presence  of  twins,  which  may  be  still 
further  increased  by  hydramnios  of  one  ovum.  This  may  give  rise  to 
considerable  discomfort,  the  patient  suffering  markedly  from  dyspnoea, 
pressure  symptoms,  and  oedema. 

Occasionally  the   extreTiie~"st"retching  of  the  uterus  may  lead  to   an 
early  dilatation  of  the  cervix.     Thus,  in  one  instance,  I  found  the  cer- 
vical canal  completely  obliterated  and  the  os  externum  dilated  to  5  centi- 
metres three  weeks  before  the  onset  of  labour.     Eeference  has  already 
been  made  to  the  frequency  of  premature  expulsion  in  these  cases;  and  when 
labour  sets  in,  owing  to  the  overdistention  of  the  uterus,  the  pains  usually  \ 
occur  at  long  intervals  and  are  lacking  in  intensity,  so  that  the  birth  of  I 
the  first  child  is  often  markedly  prolonged.     The  cord  of  this  child  should    ' 
be  cut  between  double  ligatures,  as  failure  to  ligate  its  maternal  end  may 
lead  to  the  death  of  the  second  child  from  hsemorrhage  if  the  twins  are 
-derived  from  a  single  ovum. 

Generally  speaking,  the  membranes  of  the  second  child  appear  at  the 
cervix  immediately  after  the  first  is  born  and  soon  rupture.     Its  expul- 


MULTIPLE    PREGNANCY 


333 


sion  usually  follows  the  firsl  within  half  an  hour,  75  per  cent  of  the 
cases  collected  by  Oeinwachter  occurring  within  this  period;  while  in  the 
remainder  a  longer  timo  elapsed— as  much  as  twelve  liours  in  ]  of  his 
cases.  As  a  rule  it  may  be  said  that  if  spontaneous  delivery  of  the  second 
child  docs  not  occur  within  half  an  hour  interference  is  indicated. 

Changes  in  position  of  the  second  child  not  infrequently  occur  dur- 
ing and  just  alter  the  birth  of  the  first,  so  that  at  this  time  a  renewed 
examination  is  necessary 
in  order  that  any  abnor- 
mality may  be  detected 
and  the  proper  measures 
taken.  The  condition  of 
the  foetal  heart  should 
also  be  carefully  watched, 
and  delivery  immediately 
effected  if  it  becomes  ab- 
normal. In  most  cases 
both  twins  present  by  the 
vertex,  though  not  very 
rarely  one  descends  by  the 
breech.  In  316  cases  an- 
alyzed by  Depaul  and 
Tarnier,  the  following 
were  noted:  Both  vertices 
in  131  cases;  vertex  and 
breech  in  81  cases;  breech 
and  vertex  in  47  cases; 
both  breeches  in  29  cases; 
breech  and  shoulder  in  -1 
cases;  vertex  and  face  in  -I 
cases;  other  combinations 
occurring  in  a  small  num- 
ber of  cases. 

As  a  rule  the  placenta 
of  the  first  child  remains 
in  si I ii  until  the  comple- 
tion of  labour,  but  in  rare 
instances  it  may  become 
partly  or  completely  sepa- 
rated   and    give    rise    to 

haemorrhage.     Under  these  circumstances  the  second  child  should  be  de- 
livered at  once. 

Owing  to  previous  overdistention,  the  uterus  not  infrequently  fails 
to  contract  and  retract  satisfactorily  during  the  third  stage  of  labour, 
so  that  abnormalities  in  the  placental  period  are  not  infrequent.  If  there 
is  any  tendency  toward  an  excessive  loss  of  blood,  the  obstetrician  should 
immediately  express  the  placenta  by  Crede's  method,  instead  of  waiting 
for  the  fundus  to  rise  up.     Occasionally  the  area  of  placental  attachment 


Fig.  315. 


Diagram  shoeing  Collision  bettveex  Heads  of 
Twins. 


t 


334 


OBSTETRICS 


may  be  so  large  that  abnormalities  in  its  detachment  may  render  neces- 
sary its  manual  removal.  This  operation,  however,  should  not  be  resorted 
to  unless  urgently  indicated. 

The  danger  of  haemorrhage  does  not  end  with  the  expulsion  of  the 
placenta,  as  the  uterus  sometimes  relaxes  during  the  hour  immediately 
following.  Accordingly,  the  physician  should  remain  in  the  house  for 
some  time  after  the  completion  of  labour  and  give  his  personal  supervision 
to  the  condition  of  the  uterus,  kneading  it  upon  the  first  indication  of 
relaxation,  and  re-enforcing  it  by  the  hypodermic  administration  of  ergot. 
Neglect  in  this  direction  has  sometimes  led  to  the  death  of  the  patient 
from  post-partum  haemorrhage. 

Owing  to  the  small  size  of  the  children,  their  presenting  parts  may 
both  attempt  to  enter  the  superior  strait  at  the  same  time  and  thus 
mutually  interfere  with  one  another.  This  complication  is  known  as 
collision,  and  may  occur  when  both  children  present  by  the  vertex,  or 
when  one  presents  by  the  head  and  the  other  by  the  breech.  "  In  the 
first  case  an  attempt  should  be  made  to  push  up  the  presenting  part, 
which  is  less  distinctly  engaged,  and  then  deliver  the  other  child  rapidly. 
If  this  is  nor  possible,  the  whole  hand  should  be  introduced  into  the 
uterus  and  the  condition  of  affairs  carefully  studied.     Occasionally  it  will 

be  found  advisable  to  apply  forceps 
to  the  uppermost  child  and  attempt  to. 
drag  it  past  the  other.  In  rare  in- 
stances craniotomy  upon  one  child 
may  be  indicated. 

Now  and  again  during  extraction, 
when  the  first  child  presents  by  the 
breech  and  the  second  by  the  vertex, 
the  two .  heads  may  become  locked 
just  above  the  superior  strait,  that  of 
the  second  fitting  into  the  neck  of 
the  first  child  and  making  its  deliv- 
ery impossible.  Under  such  circum- 
stances, if  the  head  of  the  second 
child  cannot  be  displaced,  the  first 
child  should  be  decapitated,  as  it  must 
inevitably  perish  during  any  attempt 
at  extraction;  after  this  the  body 
should  be  brought  away  and  the  sec- 
ond child  then  delivered  by  forceps. 

In  rare  instances  the  first  child 
may  present  transversely  and  be  strad- 
dled by  the  second  in  such  a  mariner  that  the  legs  of  the  latter  protrude 
from  the  cervix.  Traction  upon  them  will  serve  only  to  wedge  the  shoul- 
der of  the  other  child  more  firmly  into  the  pelvis  and  give  rise  to  insuper- 
able difficulties.  The  proper  treatment  can  only  be  determined  after 
most  careful  examination  under  anaesthesia  with  the  entire  hand  in  the 
uterus,  as  the  second  child  cannot  be  born  until  the  delivery  of  the  first 


Fig.  316. — Diagram  illustrating  Locked 
Twins  (Americau  Text-Book). 


MULTIPLE   PREGNANCY  335 

has  been  ell'ected.     The  condition  may  call  for  version  or  decapitation, 
according  to  the  exigencies  of  the  individual  case. 

LITERATURE 

Ahlfkld.     Die  Entstehung  der  Doppelbildungen  und  der  homologen  Zwillinge.    Arcliiv 

f.  Gyn.,  1876,  ix,  196-251. 
Lehrbuch  iter  Geburtshiilfe,  II.  Aufl.,  1898,  356-362. 
Bertillon.     Bulletin  de  la  Soc.  d'Anthropologie  dc  Paris,  1874,  ix,  267-290. 
Depaul.     Lecons  do  clinique  obstetricale.    Paris,  1876. 
Duncan.     On  Some  Laws  of  the  Production  of  Twins.     Edinburgh  Med.  Jour.,  March, 

1865. 
von  Franque.      Beschreibung  einiger  seltener  Eierstockspriiparate.     Zeitschr.  f.  Geb.  u. 

Gyn.,  1898,  xxxix,  326-346. 
Hellin.     Die  Ursache  der  Multiparitat  der  uniparen  Tiere,  etc.     Miinchen,  1895. 
Hermann.     Ueber  Verschlingungen  der  Nabelschniir  bei  Zwillingen.     Archiv  f.  Gyn.- 

1891,  xl,  253-260. 
Kleinwachter.     Die  Lehre  von  den  Zwillingen.     Prag,  1871. 
Klien.     Ueber  inehreiige  Graaf'sche  Pollikel  beira  Menschen.    Munchener  med.  Abhand, 

lungen,  1898,  IV.  Reihe,  Heft  4. 
Larger.     Les  stimates  obstetricaux  de  la  degenerescence.     These  de  Paris,  1901. 
Mirabeau.     Ueber  Drillingsgeburten.     Munchener  med.  Abhandlungen,  1894,  IV.  Reihe, 

Heft  5. 
Patellani.    Die  mehrfachen  Schwangerschaften,  etc.     Zeitschr.  f.  Geb.  u.  Gyn.,  1896, 

xxxv,  373-413. 
Pinard.     Quoted  by  Ribemont-Dessaignes. 
Puech.     Des  grossesses  multiples,  etc.     Paris,  1873. 
Ribemont-Dessaignes    et    Lepage.       Precis  d'Obstetrique,   1894,   864-897.      (Grossesse 

gemellaire.) 
Saniter.     Drillingsgeburten.     Eineiige  Drillinge.     Zeitschr.  f.  Geb.  u.  Gyn.,  1901,  xlvi, 

347-385. 
Schatz.       Die    Gefassverbindungen    der    Placentakreislaufe    eineiiger    Zwillinge,    ihre 

Entwickelung  und  ihre  Folgen.     Archiv  f.  Gyn.,  1882-1900,  Bde.  xix,  xxiv,  xxvii, 

xxix,  xxx,  liii,  Iv,  lviii  und  Ix. 
Sobotta.     Neuere  Anschauungen  iiber  die  Entstehung  der  Doppel-(miss)-bildungen,  etc. 

Wiirzburger  Abhandlungen,  1901,  Bd.  1,  Heft  4. 
Tarnier  et  Chantreuil.     Des  grossesses  multiples.     Traite  de  l'art  des  accouchements, 

Paris,  1888,  t.  i,  543-563. 
Vassalli.     Caso  di  gravidanza  sesquilgemellare.     Gazette  medica  Italiano-Lombardia, 

1888,  Nr.  38,  216. 
Veit,  G.     Beitrage  zur  geburtshiilflichen  Statistik.     Monatsschr.  f.  Geburtsk.,  1855,  vi, 

126-132. 
Viardel.     Anmerkungen  von  der  weiblichen  Geburt.     Frankfurt,  1676,  21. 
Wappaeus.     Allg.  Bevolkerungsstatistik.     Leipzig,  1859. 


OBSTETRIC    SURGERY 


CHAPTER  XIX 


INDUCTION  OF  ABORTION  AND  PREMATURE  LABOUR— 
ACCOUCHEMENT  FORCE 

Preparations  for  Obstetrical  Operations. — Owing  to  the  increased  ma- 
nipulation within  the  generative  tract  incident  to  an  obstetrical  operation, 
any  lack  of  cleanliness  entails  even  more  risk  than  in  the  case  of  normal 
labour.  Accordingly,  the  maintenance  of  a  rigid  aseptic  technique  is  abso- 
lutely imperative. 

The  hands  of  the  operator  and  his  assistants  should  be  thoroughly  pre- 
pared by  prolonged  scrubbing  with  a  nail-brush,  plenty  of  hot  water  and 


^MtfHfifiBflB 


Fig.  317, — Showing  Patient  at  Edge  of  the  Bed,  with  Legs  held  in  Position  by 

Leg-Holder. 

green  soap  being  used,  after  which  they  should  be  passed  successively 
through  permanganate  of  potassium,  oxalic  acid,  and  bichloride  solutions, 
as  described  when  considering  the  conduct  of  a  normal  labour.     If  the 


'REPARATIONS   FOR   OBSTETRICAL   OPERATIONS 


337 


hands  have  recently  come  in  contact  with  septic  material,  or  if  the  patient 
be  infected,  or  presenl  syphilitic  lesions  about  the  vulva,  tliin  rubber  gloves 
are  necessary.  CTnder  oilier  circumstances  they  may  be  employed  or  not, 
according  to  the  practice  of  the  operator. 


vered  with  Sterile  Dressings  Preparatory  to  Operation. 


A  sufficient  quantity  of  dressings,  towels,  gauze,  absorbent  cotton,  and 
ligatures,  carefully  sterilized  beforehand,  should  be  in  readiness.  All  in- 
struments should  be  rendered  sterile  by  boiling  immediately  before  the 
operation.  As  an  emollient,  vaseline,  which  has  beeen  sterilized  by  boiling 
in  small  jars,  will  serve  every  purpose. 

The  external  genitalia  are  thoroughly  cleansed  with  green  soap  and 
hot  water,  rinsed  off  with  sterile  water,  freely  irrigated  with  a  l-to-2,000 
bichloride  solution,  and  finally  covered  with  a  towel  soaked  in  the  same, 
which  should  remain  in  place  until  the  operation  is  begun.  If  the  pubic 
hairs  are  long  and  abundant  they  should  be  cut  short  with  scissors  or  re- 
moved entirely  with  a  razor. 

If  the  woman  is  uninfected,  it  is  not  necessary  to  attempt  to  disinfect 


338  OBSTETRICS 

the  vagina  by  means  of  antiseptic  irrigations  or  other  manipulations.  But 
if  the  temperature  is  elevated,  or  the  patient  has  been  subjected  to  re- 
peated examinations  or  attempts  at  delivery,  a  vaginal  douche  of  a  1-to- 
5,000  bichloride  solution  may  be  given. 

Obstetrical  operations,  with  the  exception  of  Caesarean  section  and  sym- 
physeotomy, are  usually  undertaken  with  the  patient  in  the  lithotomy  posi- 
tion. As  the  ordinary  low  beds  now  in  use  are  very  inconvenient  for  the 
performance  of  an  operation,  it  is  advisable,  as  a  rule,  even  in  private 
practice,  to  place  the  patient  upon  a  narrow  table:  one  that  will  answer 
the  purpose  quite  satisfactorily  is  usually  to  be  found  in  every  kitchen. 
Anaesthesia  is  indispensable  for  all  but  the  simplest  operative  procedures, 
and  as  soon  as  the  patient  is  fully  under  its  influence  her  buttocks  should 
be  brought  to  the  edge  of  the  table  and  her  legs  held  in  place  by  a  leg- 
holder.  If  a  table  is  not  available,  the  patient  should  be  placed  crosswise  in 
bed  with  her  buttocks  protruding  over  its  edge.  The  nightgown  should 
be  rolled  up  above  the  hips  to  avoid  soiling,  and  as  soon  as  the  external 
genitalia  have  been  prepared,  the  patient's  legs  should  be  encased  in  sterile 
stockings  made  especially  for  this  purpose,  and  her  abdomen  and  buttocks 
covered  with  sterile  towels  in  such  a  manner  as  to  leave  only  the  genitalia 
exposed.  To  avoid  the  possibility  of  contamination  from  the  rectum,  it  is 
advisable  to  first  empty  the  lower  bowel  by  means  of  an  enema,  and  then 
cover  the  anus  with  a  folded  sterilized  towel,  which  can  be  held  in  place 
by  a  strip  of  adhesive  plaster  passed  over  the  buttocks,  after  which  a  spe- 
cially prepared  sterile  sheet  should  cover  everything  except  the  immediate 
field  of  operation. 

Induction  of  Abortion. — By  this  term  is  understood  the  artificial  ter- 
mination of  pregnancy  before  the  foetus  has  attained  viability — namely, 
prior  to  the  twentv-eighth  week..  The  operation  dates  from  the  most  re- 
mote antiquity,  and  more  or  less  accurate  directions  for  its  performance 
are  to  be  found  in  the  earliest  writings  upon  medicine.  It  was  so  exten- 
sively practised  in  Eome  that  we  find  it  repeatedly  referred  to  by  Plautus, 
Juvenal,  and  other  secular  writers  as  a  matter  of  every-day  occurrence. 
With  the  spread  of  Christianity,  however,  it  came  to  be  considered  as 
criminal,  except  when  undertaken  as  a  last  resort  in  order  to  save  the  life 
of  the  mother;  and  we  now  draw  a  sharp  distinction  between  criminal  and 
therapeutic  abortion.  For  full  historical  details  the  reader  is  referred  to 
the  works  of  Levin  and  Brenning,  Brouardel  and  Kleinwachter. 

Indications. — Three  groups  of  cases  may  offer  an  indication  for  the 
operation.  Thus  we  may  think  it  our  duty  to  induce  an  abortion:  (1)  As 
a  direct  means  of  gayino-  fhp  Ijfp  nf  the  mother:  (2)  to_do  away  with"  a 
condition  which  may  threaten  her  life  if  gestation  continues;  and  (3)  to 
avoid  certain  dangers  which  may  supervene  if  pregnancy  is  allowed  to 
progress  to  full  term. 

Under  no  circumstances  should  the  operation  be  undertaken  unless  a 
careful  and  thorough  examination  has  demonstrated  that  the  patient  is 
in  a  most  serious  condition.  Her  statements  are  entitled  to  but  little 
weight,  and  the  decision  to  interfere  should  be  based  entirely  upon  objective 
symptoms  and  conditions.    Moreover,  the  operation  should  never  be  under- 


Tf 


INDUCTION   OF   ABORTION  339 

taken  without  a  consultation  with  a  second  physician,  who  assumes  his  share 
ot'  ilif1v>[M>nsii)ility.  This  precaution,  besides  securing  for  the  patient 
additional  advice,  will  protect  the  physician  from  a  possible  blackmailing 
on  the  part  of  unscrupulous  persons. 

Iu  the  lirst  -r«ai|).  tin-  I ><>t- recognised  indication  for  the  operation  is 
present  when  the  rmiiU'nuj  <>f  prci/nanri/  i>  uncontrollable.  In  mos1  cases  II 
this  symptom  amounts  to  nothing  more  than  a  serious  annoyance,  and  can 
be  relieved  by  appropriate  medical  and  dietetic  measures,  more  particularly 
by  the  temporary  employment  of  rectal  feeding;  but  now  and  again  every 
attempt  will  prove  unavailing,  and  the  condition  becomes  so  serious  that 
the  patient  is  in  danger  of  starvation  unless  promptly  relieved. 

Owing  to  the  fact  that  the  vomiting  of  pregnancy  usually  ceases  spon- 
taneously, or  becomes  better  under  treatment,  there  is  a  natural  hesitancy 
on  the  part  of  the  physician  to  interfere.  For  this  reason  the  operation 
is  not  infrequently  postponed  until  the  condition  of  the  patient  has  become 
so  serious  that  death  is  the  inevitable  consequence  whether  abortion  be 
induced  or  not.  Accordingly,  when  all  food  is  vomited,  the  patient  is 
rapidly  becoming  emaciated,  and  the  pulse  is  very  rapid,  there  should  be 
no  hesitation  as  to  the  propriety  of  interference,  and  radical  measures 
should  be  resorted  to  while  they  still  offer  a  reasonable  chance  of  saving 
the  woman's  life.  Almost  every  year  I  see  one  or  more  cases  in  which  pro- 
crastination has  led  to  the  death  of  the  patient. 

The  induction  of  abortion  is  likewise  urgently  indicated  when   the 
uterine  contents  have  become  infected,  a  condition  which  frequently  fol-    2 
lows  attempts  at  criminal  abortion.     Cnder  such  circumstances,  if  the  foetus  S 
has  not  already  succumbed  it  will  almost  certainly  die,  and  the  only  chance 
of  saving  the  woman's  life  lies  in  promptly  emptying  the  uterus  and  cleans- 
ing its  cavity. 

Formerly  it  was  believed  that  abortion  should  be  induced  for  incar- 
ceration of  the  retro-flexed  pregnant  uterus,  as  well  as  in  the  rare  cases  of  "& 
hernia  of  that  organ,  inasmuch  as  death  is  the  usual  result  if  the  patient 
be  left  to  herself.  At  present,  however,  better  results  are  obtained  in  the  ^« 
former  condition  by  performing  kparotomv^ freeing  the  uterus  from  ad- 
hesions and  replacing  it  in  a  normal  position,  after  which  pregnancy  not 
infrequently  pursues  an  uninterrupted  course. 

In  the  second  group,  marked  renal  insufficiency  or  acute  nephritis  may     i\ 
necessitate  the  operation.    But  inasmuch  as  such  "conditions  usually  make 
their  appearance  only  when  pregnancy  is  well  advanced,  they  will  be  con- 
sidered when  we  take  up  the  induction  of  premature  labour. 

Diseases  of  the  ovum,  such  as  hvdatidiform  mole  and  hydramnios.  occa- 
sionally  afford  an"  lrir lication  for  the  operation.  TThenever  the  former  con- 
dition is  diagnosticated  the  uterus  should  be  emptied_at  once,  no  matter 
"what  be  the  period  of  pregnancy,  as  under  such  circumstances  the  foetus  is 
either  dead  or  very  imperfectly  developed,  and  if  the  diseased  chorion  be 
allowed  to  remain  in  the  uterus,  a  deciduoma  malignum — a  chorio-epithe- 
lioma — may  develop. 

Uterine  haemorrhage  in  the  early  months  of  pregnancy  is  generally  a 
sign  of  beginning  spontaneous  abortion,  but  if  the  loss  of  blood  continues 
23 


340 


OBSTETRICS 


for  some  time  and  is  not  followed  by  expulsion  of  the  ovum,  the  uterus 
should  be  emptied  by  operative  means.  Later  in  pregnancy  the  most  fre- 
quent cause  of  haemorrhage  is  a  faulty  implantation  of  the  placenta,  par- 
ticularly placenta  prasvia,  and  under  such  circumstances  delivery  should 
be  effected  as  soon  as  possible.  The  rare  cases  of  missed  abortion,  in  which 
the  ovum  is  retained  for  weeks  or  months  after  the  death  of  the  embryo, 
demand  that  the  uterus  should  be  emptied  as  soon  as  serious  symptoms 
appear. 

The  indications  in  the  third  group  are  afforded  by  markedly  contracted 
pelves  or  tumour  formations.  Formerly,  the  induction  of  abortion  at  an 
early  period  was  considered  justifiable  when  the  pelvis  was  so  contracted 
as  to  present  an  absolute  indication  for  Csesarean  section;  but  at  present, 
in  view  of  the  excellent  results  which  attend  the  latter  operation,  this  view 
has  been  modified.  The  same  applies  when  pregnancy  is  complicated 
by  the  presence  of  uterine  mj/omata  or  ovarian  cysts.  In  the  former  class  of 
cases,  if  the  symptoms  are  urgent,  hysterectomy  should  be  promptly  per- 
formed without  regard  to  the  existence  of  pregnancy;  but  if  the  tumour 
promises  to  act  merely  as  a  mechanical  obstacle  to  labour,  pregnancy  should 
be  allowed  to  go  on  to  term,  and  Cesarean  section  then  performed,  followed 
by  removal  of  the  uterus. 

Ovarian  tumours  complicating  pregnancy  should  be  removed  bv  lapa- 
rotomy as  soon  as  the  cli'apnos|s  is  made.  In  many  such  cases  this  can 
be  done  without  causing  interruption  of  the  pregnancy,  and  spontaneous 
delivery  will  occur  at  term. 

The  induction  of  abortion  is  not  indicated  in  malignant  growths, 
whether  they  affect  the  uterus  or  adjacent  organs.  In  carcinoma  of  the 
cervix  the  treatment  to  be  pursued  differs  according  to  circumstances.  If 
the  case  be  operable,  immediate  hysterectomy  is  indicated  without  regard  to 
the  presence  oPpregnancy;  but  if  the  disease  has  progressed  too  far  to  offer 
a  prospect  of  permanent  cure  after  operation,  gestation  should  be  allowed 
to  continue  in  the  interests  of  the  child,  which  should  be  delivered  at 
term  by  the  procedure  most  appropriate  to  the  particular  case. 

Methods  of  Inducing  Abortion. — Generally  speaking,  the  methods  of  in- 
ducing  abortion  vary  according  to  the  duration  of  pregnancy.    In  the  first 

foiir  months  the  operation  can 
usually  be  completed  at  a  sin- 
gle sitting,  whereas  between 
this  period  and  the  seventh 
month  the  methods  employed 
for  the  induction  of  premature 
labour  are  more  appropriate. 
In  the  first  period,  the  cervix  should  be  dilated  sufficiently  to  admit  at  least 
onefiug-ei\  "For  tin's  purpose  Goodell's  or  Hegar's  dilators  will  be  found  very 
convenient.  The  entire  hand,  anointed  with  sterile  vaseline,  is  then  intro- 
duced into  the  vagina  and  the  index  finger  carried  up  into  the  uterine 
cavity;  while  the  other  hand,  placed  upon  the  abdomen,  forces  the  uterus 
downward.  With  the  finger  within  the  uterus  the  placenta  is  separated 
from  its  attachments,  after  which,  according  to  the  duration  of  pregnancy, 


Fig.  319. — Goodell's  Dilator. 


.     INDUCTION  OF   gREMATURE   LABOUR  341 

the  product  of  conception  is  removed  entire  or  is  broken  up  into  small  \ 
pieces,  which  can  be  removed  by  means  01  an  abortion  or  ovum  forceps. 

To  attempl   to  empty  the  uterus  blindly  by  means  of  a  curette  ami 
ovum   forceps  is  an   unwise  procedure,  inasmuch   as   many  cases  are   re- 
ported in  which  such  operations  have  caused  perforation.    Still  more  fre- 
quently   Larger   or   smaller    por- 
tions   of   the   placenta   are    left    CZ!)  

behind  in  the  uterus,  giving  rise    ^J 
by  their  presence  to  serious  haem-  Fig.  320.— Owm  Forceps. 

orrhage  and  occasionally  to  infec- 
tion.   Accordingly,  one  can  never  feel  sure  that  the  operation  is  complete 
unless  one  or  more  fingers  have  been  introduced  into  the  uterus  and  care- 
fully palpated  its  interior. 

In  rare  cases  the  cervix  may  be  so  resistant  as  to  render  rapid  dilatation  *J 
impossible.  Under  such  circumstances  a  strip  of  sterile  gauze  should  be  *■» 
tightly  packed  into  the  canal  and  the  vagina  firmly  tamponed  with  the 
same  material.  Half-drachm  doses  of  ergot  should  then  be  administered 
every  four  hours.  When  the  pack  is  removed  at  the  end  of  twenty-four 
hours  the  entire  ovum  will  frequently  follow  it;  while  in  other  cases  the 
cervix  will  be  sufficiently  softened  to  permit  the  introduction  of  the  finger, 
or  at  least  of  its  dilatation  with  a  suitable  instrument.  The  employment 
of  a  laminaria  tent  has  been  recommended  by  many  authorities  in  place  of 
the  pack,  but  in  my  opinion  its  use  adds  somewhat  to  the  risk  of  infection. 

Abortion  is  sometimes  induced  by  ppTJorairnp-_thft  -membranes  with  a     3  j 
sterile  sound  and  allowing  the  liquor  amnii  to  drain  off.    The  desired  result,    -V 
however,  does  not  always  follow  this  manoeuvre,  and  it  frequently  becomes 
necessary  to  supplement  it  by  one  of  the  procedures  just  described. 

Prognosis. — The  prognosis  varies  according  to  the  indication  for  which 
the  operation  is  undertaken,  but  with  the  patient  in  fairly  good  condition 
satisfactory  results  should  always  follow,  provided  a  rigid  aseptic  technique 
is  observed. 

Induction  of  Premature  Labour. — By  this  term  we  designate  the  arti- 
ficial termination  of  pregnancy  after  the  child  has  reached  the  period  of 
viability — that  is,  affpr  thP  t^prttv-pio-hth  wppIc.  The  operation  was  per- 
formed by  Guillemeau,  Maurieeau,  Justine  Siegemundin,  and  others  in 
isolated  cases  for  haemorrhage,  but.  according  to  Denman,  it  was  not  gen- 
erally- advocated  until  1756,  when  a  conference  of  physicians  was  held  in 
London  to  devise  means  for  doing  away  with  the  frightful  mortality  fol- 
lowing Cesarean  section  for  contracted  pelves. 

Indications. — The  indications  for  the  operation  are  twofold:  to  obviate     H  ^  • 
the  dangers  attending  deliverv  at  term  through  a  contracted  pelvis,  and 
to  save  the  life  of  the  mother  when  seriously  threatened  by  some  disease    ^ 
from  which  she  may  be  suffering,  or  on  account  of  some  pathological  con- 
dition existing  in  the  ovum.  'I 

In  contracted  pelves  premature  labour  is  induced  with  the  idea  that£    ^ 
the  imperfectly  developed  child  will  be  born  more  readily  than  at  term.       p  i 

This  view  is  undoubtedly  correct,  and  if  the  welfare  of  the  mother  alone 

were  concerned  the  operation  should  be  undertaken  in  all  cases.     On  the 


342  OBSTETRICS 

other  hand,  the  interests  of  the  child  are  entitled  to  some  consideration. 
We  know  that  labour  will  be  easier  the  earlier  the  operation  is  performed, 
but  it  must  be  remembered  that  the  child  will  be  less  liable  to  survive  it,  and 
even  if  born  alive  its  chances  of  succumbing  to  accidental  causes  after  its 
birth  will  be  proportionately  greater.  Inasmuch,  then,  as  the  later  the 
operation  the  better  the  outlook  so  far  as  the  child  is  concerned,  the  induc- 
tion of  premature  labour  should  not  be"  attempted  before  the  thirty-fourth, 
and  preferably  not  before  the  thirty-sixth,  weekjxf  pregnancy. 

The  question  as  to  the  propriety  of  the  operation  has  given  rise  to  an 
extensive  literature.  At  the  International  Medical  Congress  of  1890,  held 
in  Berlin,  it  was  one  of  the  chief  subjects  under  discussion.  On  that  occa- 
sion Parvin,  Macan,  Calderini,  Dohrn,  Leopold,  Lohlein,  and  others  spoke 
upon  the  subject,  and  in  the  end  it  was  agreed,  Sanger  only  dissenting,  that 

/the  operation  was  indicated  in  generally  contracted  pelves  with  a  con- 
nugata  vera  varying  from  7.5  to  9  centimetres,  and  in  flat  pelves  with  a  con- 

' ) jugata  vera  of  7  centimetres  or  more,  and  should  be  performed  as  "late  in 

'  pregnancy  as  possible,  preferably  about  the  thirty-sixth  week. 

J  I  The  principal  difficulty  connected  with  the  operation  is  to  choose  the 
correct  time  for  its  performance,  since  we  are  unable  to  determine  accu- 
rately the  size  of  the  child's  head.  The  methods  of  Miiller,  Ahlfeld,  and 
others,  to  which  reference  will  be  made  in  the  chapter  upon  the  treatment 
of  contracted  pelves,  do  not  lead  to  very  accurate  results,  so  that  owing 
to  the  desire  of  postponing  the  operation  until  the  latest  possible  moment, 
it  is  frequently  not  undertaken  until  the  child's  head  has  attained  such  pro- 
portions as  to  render  its  passage  throiigh  the  pelvis  difficult  or  impossible. 
The  results  obtained  are  extremely  satisfactory  so  far  as  the  mother  is 
concerned,  the  maternal  mortality  being  only  1.03  per  cent  in  391  opera- 
tions performed  by  Ahlfeld,  Bar,  Leopold,  and  Pinard.  On  the  other  hand, 
the  foetal  mortality  is  relatively  high,  varying  from  45  to  12  per  cent,  ac- 
cording to  the  statistics  from  various  lying-in  hospitals.  Kleinwachter, 
after  an  exhaustive  study  of  the  subject,  concludes  that  78.3  per  cent  of  the 
children  are  born  alive,  but  that  many  of  them  die  soon  after  birth,  and 
only  60.4  per  cent  leave  the  hospital  in  good  condition.  According  to  these 
figures,  then,  the  net  mortality  would  be  39.6  per  cent;  but  when  we  con- 
sider that  most  careful  nursing  and  appropriate  feeding  are  afterward 
necessary,  it  is  apparent  that  no  inconsiderable  portion  of  the  children 
dismissed  from  the  hospital  in  good  condition  must  inevitably  perish  within 
the  first  year,  and  it  is  hardly  an  exaggeration  to  state  that  hardly  one  third 
of  those  born  survive  that  period.  It  would  therefore  appear  that  the  ulti- 
mate results,  so  far  as  the  children  are  concerned,  are  so  poor  as  not  to  com- 
mend the  operation  to  favourable  consideration. 

In  this  connection,  it  is  important  not  to  lose  sight  of  the  fact  that  prac- 
tically 70  per  cent  of  all  labours  occurring  in  contracted  pelves  end  with- 
out artificial  aid,  and  that  it  is  extremely  difficult  in  the  degrees  of  contrac- 
tion under  consideration  to  foretell  in  a  given  case  whether  spontaneous  de- 
livery will  occur  or  not.  Personally  I  have  had  a  gross  f cetal  mortality  of 
only  13  per  cent  in  a  series  of  278  cases  of  contracted  pelves  in  which  pre- 
mature labour  was  not  induced,  and  these  figures,  when  taken  in  connection 


u 


H 


•     INDUCTION    OF    I'RKMATURH    LABOUR  343 

witli  those  of  others,  arc  certainly  tiol  in  favour  of  I  lie  opera!  ion.  Moreover, 
if  (he  rules  laid  down  in  the  chapter  on  (he  Irealnieni  of  Labour  com- 
plicated by  contracted  pelves  be  followed,  and  Cesarean  see! ion  promptly 
performed  when  indicated,  the  foetal  mortality  should  he  practically  aoth- 
ing,  or  ai  leas!  aot  much  greater  than  with  normal  pelves. 

At  present  Pinard  considers  the  induction  of  labour  no  longer  justi- 
fiable, and  advocates  allowing  all  cases  to  go  on  to  term,  when  symphyse- 
otomy is  performed  if  necessary.  Bar,  who  has  had  a  large  experience  with 
the  induction  of  premature  labour,  has  likewise  abandoned,  it,  and  recom- 
mends the  performance  of  Csesarean  section  at  term  if  spontaneous  deliv- 
ery does  not  occur.  So  far  as  my  own  experience  goes,  I  am  heartily  in 
accord  with  this  last  authority,  and  believe  that  this  practice  would  effect 
the  saving  of  nearly  all  the  children;  whereas  by  the  induction  of  premature 
labour  a  much  smaller  number  will  be  brought  into  the  world  alive,  many 
of  whom  are  doomed  to  certain  death  or  to  lifelong  afflictions. 

At  the  present  time,  then,  it  seems  to  me  that  the  only  rational  indica-  f2/ 
tion  for  the  induction  of  prernature  labour^  so  far  as  concerns  the  existence  * 
of  disproportion  between  the  size  of  the  head  and  the  pelvis,  is  afforded  by 
the  rare  cases  in  which  the  pelvis  is  normal  but  the  child  abnormally  l^rge^ 
owing  either  to  excessive  development  or  to  an  undue  prolongation  of  preg- 
nancy. If  such  a  condition  be  diagnosed  some  weeks  before  labour,  the 
operation  is  clearly  indicated,  particularly  in  multiparous  women  who  have 
repeatedly  given  birth  to  very  large  dead  children. 

The  most  usual  indication  for  the  operation,  however,  is  afforded  by 
diseases  which  threaten  the  life  of  the  mother,  while  at  the  same  time 
there  exists  a  probability  of  cure  after  the  termination  of  gestation.  This  3/}  ^ 
is  particularly  true  in  those  cases  of  toxcemia  or  acute  nephritis  complicat- 
ing pregnancy,  which  show  no  tendency  to  subside  in  spite  of  appropriate 
treatment.  Experience  teaches  that  under  such  circumstances,  even  if 
pregnancy  be  allowed  to  continue,  premature  labour  frequently  occurs  spon- 
taneously, when  a  large  proportion  of  the  children  are  born  dead,  or,  if 
alive,  very  imperfectly  developed.  Moreover,  one  should  also  take  into 
consideration  the  possibility  that  the  renal  changes  may  become  chronic. 
Accordingly,  if  alarming  symptoms  supervene,  labour  should  be  induced  at 
any  period  of  pregnancy  without  too  conservative  a  regard  for  the  life  of 
the  child. 

In  patients  presenting  nephritic  symptoms,  the  total  amount  of  albumin 
and  urea  contained  in  the  twenty-four  hours'  urine  should  be  determined 
daily,  and  whenever  there  is  a  steady  increase  in  the  amount  of  albumin 
and  a  corresponding  decrease  in  the  amount  of  urea,  in  spite  of  appro- 
priate treatment,  labour  should  be  induced  in  the  hope  of  preventing  the 
onset  of  eclampsia.  If  eclampsia  supervenes,  pregnancy  should  be  termi- 
nated as  soon  as  possible  by  accouchement  force,  if  the  condition  of  the  cervix 
permits;  but  if  this  procedure  promises  to  be  very  difficult  delivery  should 
be  effected  by  slower  and  less  violent  means. 

Cardiac  lesions  occasionally  demand  the  induction  of  premature  labour, 
but  this  should  be  resorted  to  only  in  cases  of  broken  compensation  which 
do  not  yield  to  appropriate  treatment. 


314  OBSTETRICS 

From  the  time  of  D'Outrepont  (1828),  it  has  "been  recommended  that 
^  ,       the  operation  be  undertaken  in  the  interests  of  the  child  in  the  rare  cases 
of  tuberculosis  in  which  the  condition  of  the  mother  is  so  serious  as  to 
make  it  probable  that  she  will  not  live  until  term. 

Spontaneous  interruption  of  pregnancy  frequently  occurs  during  the 

J-      course  of  the  acute  infectious  diseases — pneumonia,  typhoid  fever,  etc. — 

but  inasmuch  as  experience  has  shown  that  it  materially  increases  the  risks 

to  the  mother,  the  induction  of  premature  labour  is  contra-indicated. 

In  rare  instances  a  general  peripheral  neuritis  may  so  endanger  the  life 

—  of  the  mother  as  to  call  for  interference.  Lepage  and  Sainton  (1901)  re- 
ported a  case  of  alcoholic  origin  in  which  the  induction  of  labour  was  fol- 
lowed by  most  happy  results. 

The  milder  forms  of  chorea  complicating  pregnancy  are  usually  readily 
j.  -  amenable  to  treatment,  but  when  the  disease  assumes  a  grave  type  it  is  at- 
^-^   tended  with  great  danger,  the  maternal  mortality,  according  to  Fehling, 
being  36  per  cent.    Therefore,  if  the  patient  appears  to  be  in  serious  "danger, 
premature  delivery  should  be  brought  about,  as  experience  has  shown  that 
the  emptying  of  the  uterus  is  usually  followed  by  marked  improvement. 
In  patients  suffering  from  diabetes,  gestation  sometimes  exerts  a  very 
~"""J   deleterious  influence  upon  the  course  of  the  disease.     Accordingly,  if  the 
"•      patient's  condition  becomes  alarming,  labour  should  be  induced.     In  the 
majority  of  cases,  however,  the  so-called  diabetes  of  pregnancy  is  merely  a 
lactosuria  which  is  not  likely  to  be  attended  by  serious  symptoms,  the  pa- 
tients being  spontaneously  delivered  of  healthy  children  at  term. 

According  to  Graef  e  and  others,  the  occurrence  of  jDregnancy  in  patients 
suffering  from  pernicious  anosmia  or  leukaemia  adds  markedly  to  the  gravity 
of  the  condition,  so  that  in  occasional  cases  the  induction  of  premature 
labour  may  be  indicated. 

In  rare  instances  in  patients  suffering  from  pyelitis,  the  pregnant  uterus 

may  so  compress  the  ureter  as  to  cause  a  damming  back  of  the  purulent  dis- 

*  '*     charge,  and  thus  give  rise  to  a  pyelo-nephritis.    Under  such  circumstances 

—  the  induction  of  premature  labour  is  indicated.  In  two  cases  recently  under 
my  care,  interference  was  followed  by  surprisingly  good  results,  the  patients 
recovering  without  further  treatment. 

Many  authors  recommend  the  induction   of  premature  labour  when 
pregnancy  is  complicated  by  uterine  or  ovarian  tumours,  or  by  malignant 
disease  of  the  uterus  or  rectum  which  would  offer  an  insuperable  obstacle 
to  the  birth  of  a  full-term  child.    At  the  present  day.  however,  the  opera- 
tion can  hardly  be  considered  justifiable.     What  has  already  been  said  in 
connection  with  the  induction  of  abortion  under  similar  conditions,  also 
holds  good  here. 
^o-   In   hydr amnios,  when  the   abdomen   is   so   distended   as   to    seriously 
^-*»  threaten  the  life  of  the  patient,  pregnancy  should  be  terminated  without  too 
much  regard  for  the  preservation  of  the  child,  as  in  many  cases  it  is  so  poorly 
wJlctfeveloped  as  to  have  but  little  chance  of  living,  even  if  born  at  full  term. 
"~     In  cases  of  hydatidiform  mole  alarming  symptoms  usually  come  on  be- 
fore the  foetus  is  viable;  but  even  should  the  twenty-eighth  week  be  safely 
j     passed  the  immediate  termination  of  pregnancy  is  imperatively  demanded. 


'      INDUCTION   OF   PREMATURE   LABOUR  345 

Whenever  placenta  prcevia  is  positively  diagnosed,  the  termination  of 
pregnancy  is  urgently  indicated,  as  it  is  impossible  to  predict  at  what 
niouieiii  uterine  contractions  may  come  on  and  give  rise  to  profuse  or  even 
fatal  haemorrhage. 

In  rare  cases  of  habitual  death  of  the  fcetus  in  the  later  months  of 
pregnancy,  when  not  due  to  syphilis  or  renal  disease,  the  induction  of 
premature  labour  has  been  recommended  at  a  time  slightly  anterior  to 
thai  at  which  foetal  death  has  occurred  in  previous  pregnancies,  in  the 
hope  that  a  living  child  may  be  obtained.  In  such  cases  the  operation  may 
be  undertaken  if  the  parents  are  extremely  anxious  for  a  living  child, 
although  in  no  instance  should  a  positive  assurance  of  success  be  held  out 
to  them. 

Prognosis. — As  far  as  the  mother  is  concerned,  the  prognosis  of  the 
induction  of  premature  labour  is  excellent,  provided  a  rigorous  aseptic 
technique  is  observed  and  her  physical  condition  is  not  critical  at  the  time 
of  the  operation. 

The  prognosis  for  the  child  depends,  of  course,  upon  the  degree  of  its 
development,  as  well  as  upon  the  pathological  condition  for  which  the  opera- 
tion is  undertaken.  Generally  speaking,  in  the  case  of  children  born  before 
the  thirty-second  week  the  chances  of  surviving  are  very  small,  especially 
when  nephritis  or  hydramnios  affords  the  indication  for  interference. 

Methods  of  Inducing  Premature  Labour. — The  simplest  method — that  of 
Scheele — consists  m  perforating  the  membranes  with  a  sharp  instrument  -^ 
ami"  allowing  the  amniotic  fluicf  to  drain  off.  "The  results,  however,  are  un-    >v^ 
certain,  so  that  the  procedure  is  applicable  only  in  a  very  limited  number 
of  cases,  more  especially  in  hydramnios  and  occasionally  in  placenta  prasvia. 

In  the  method  most  usually  employed — that  of  Krause — a  bougie  is  in-  J&a 
troduced  between  the  membranes  and  the  uterine  wall.  In  carrying  out 
this  procedure  the  patient  is  placed  in  the  dorsal  or  Sims's  position,  and  the 
external  genitalia  carefully  disinfected.  The  cervix  is  then  brought  into 
view  by  means  of  a  speculum,  and  a  sterilized  bougie  passed  through  it  and 
gently  carried  high  up  into  the  uterine  cavity,  between  the  membranes  and 
the  uterine  wall.  In  place  of  the  bougie,  I  prefer  a  thick-walled,  rubber 
catheter,  8  to  10  millimetres  in  diameter,  which  can  be  readily  sterilized  by 
boiling.  It  should  be  introduced  by  means  of  a  copper  stylet,  which  is 
withdrawn  after  the  catheter  is  in  place. 

The  only  objection  to  Krause's  method  is  its  uncertainty.  In  many 
cases  the  introduction  of  a  single  catheter  is  followed  by  uterine  contrac- 
tions within  a  few  hours,  which  lead  to  the  expulsion  of  the  fcetus  after 
a  longer  or  shorter  period.  Not  infrequently,  however,  twenty-four  hours 
or  more  may  elapse  without  the  appearance  of  pains.  Under  such  circum- 
stances a  seqond  catheter  should  be  introduced,  to  be  followed  by  a  third  if 
necessary,  after  the  lapse  of  a  similar  period.  In  rare  instances  even  then 
the  desired  result  is  not  accomplished,  and  it  becomes  necessary  to  termi- 
nate pregnancy  in  some  other  manner.  But  for  the  general  practitioner, 
when  haste  is  not  essential,  this  is  the  safest  and  best  method  of  procedure. 

More  certain  and  rapid  results  are  obtained  by  the  use  of  the  balloon  \ 
of  Champetier  de  Eibes.    This  is  a  conical  rubber  bag  with  a  capacity  of  -100  1 


346 


OBSTETRICS 


or  500  cubic  centimetres,  from  one  end  of  which  extends  a  thick  rubber 

tube  provided  with  a  stop-cock.     The  patient  having  been  placed  in  the 

dorsal  or  Sims's  position,  the  cervix  is  brought  into  view. 

If  its  lumen  is  1.5  centimetre  in  diameter  the  bag  can 

be    passed    through    it   without    difficulty,    but    if 

smaller  it  should  be  dilated  up  to  that  size  by 

means  of  a  G-oodell  or  other  suitable  dilator. 

The  bag,  which  has  been  sterilized  by  boiling, 

is  then  tightly  rolled  into  a  cylinder,  seized     ^ 


Fig.  321. — Champetier  de  Eibes's  Balloon.  X  J. 


U 


u 


with  an  appropriately  shaped  forceps, 
thickly  smeared  with  sterile  vaseline, 
introduced  into  the  lower  uterine  seg- 
ment, and  then  pumped  full  of  sterile 
salt  solution.  Within  a  few  hours  it  usually  so  irritates  the  uterus  as  to 
induce  contractions  which  soon  lead  to  dilatation  of  the  cervix  and  the  ex- 
pulsion of  the  bag,  after  which  the  child  can  be  extracted  or  labour  allowed 
to  end  spontaneously,  according  to  the  exigencies  of  the  case.  Where  great 
haste  is  necessary,  the  dilatation  may  be  accelerated  by  attaching  a_j£ejgl 
to  the  end  of  the  tube  and  allowing  it  to  hang  over  thefoot  of  the  bed. 
This  method  gives  very  satisfactory  results,  though  it  is  evident  that  the 
introduction  of  the  large  bag  into  the  lower  uterine  segment  must  displace 
the  presenting  part,  and  occasionally  give  rise  to  malpresentations. 


Fig.  322. — Champetier  de  Eibes's  Balloon 
ready  for  introduction. 


Tarnier's  excitateur  uterir^—a  thin-walled  rubber  bag  3  or  4  centimetres 
in  diameter — and  Barnes's  fiddle-bags  are  based  upon  the  same  principle, 
but  their  smaller  size  renders  them  much  less  efficient  irritants. 

In  placenta  prsevia,  more  particularly  when  the  cervix  is  but  slightly 
dilated,  the  use  of  a  sterile  tampon  may  be  attended  by  most  excellent  re- 
sults. In  such  cases,  under  the  most  rigid  aseptic  precautions,  the  end  of 
a  sterilized  4-inch  roller  gauze  bandage  is  tightly  packed  into  the  cervical 
canal  by  means  of  a  uterine  dressing  forceps,  after  which  the  vagina  is  firmly 
and  tightly  packed  with  the  same  material.  The  pack  should  not  be  allowed 
to  remain  in  place  for  more  than  twelve  or  at  most  twenty-four  hours, 
and  on  its  removal  at  the  expiration  of  that  period  the  cervix  will  be  found 
completely  dilated,  or  at  least  sufficiently  so  to  permit  of  other  manoeuvres. 


ACCOUCHEMENT   FORCE 


347 


Numerous  other  methods  i'or  the  induction  of  premature  labour  have 
lu'cii  suggested  from  time  to  time,  among  which  may  be  mentioned  that  of 

Cohen.  This  consisted  in  the  injection  of  200  to  300  cubic  centimetres  of 
aqua  picis  between  the  uterine  wall  and  the  membranes.  Other  writers 
have  substituted  various  fluids.  Thus,  in  1891,  Pelzer  suggested  the  use  of 
100  cubic  centimetres  of  sterile  ".ivecrine,  which  promptly  gives  rise  to 
uterine  contractions.  Its  employment,  however,  is  not  to  be  recommended, 
as  it  is  occasionally  followed  by  serious  symptoms  of  intoxication,  hremo- 
globinuria,  albuminuria,  elevation  of  temperature,  cyanosis,  and  occasion- 
ally by  death.    Pfannenstiel  was  the  first  to  call  attention  to  these  dangers, 


Fig.  323. — Vaginal  and  Cervical  Pack  i>"  Position. 


and  his  warning  has  been  re-enforced  by  similar  experiences  in  the  practice 
of  other  writers.  Full  details  respecting  the  various  other  methods  sug- 
gested for  the  induction  of  premature  labour  will  be  found  in  the  mono- 
graphs of  Kleinwachter  and  Fieux. 

Accouchement  Force. — By  this  term  is  understood  the  forcible  dilatation 
of  the  intact  or  partially  dilated  cervix,  followed  by  version  and  extraction 
of  the  child.  In  pre-antiseptic  times  the  operation  was  so  universally  fol- 
lowed by  infection  that  it  fell  into  deserved  disrepute;  but  at  the  present 
day  it  has  been  rehabilitated,  and  when  properly  performed  under  suitable 
conditions  has  been  the  means  of  savins;  many  lives. 


348 


OBSTETRICS 


Generally  speaking,  if  the  cervix  be  firm  and  hard  and  the  canal  not 
obliterated,  the  operation  is  apt  to  be  very  difficult  and  occasionally  im- 
possible, while  at  the  same  time  it  is  attended  with  considerable  risk  to  the 
mother.  On  the  other  hand,  when  the  cervix  is  soft  and  the  internal  os  par- 
tially dilated,  the  operation  is  readily  performed,  and  is  followed  by  most 
satisfactory  results.  As  a  general  rule,  it  is  more  difficult  in  primiparous 
than  in  multiparous  women. 

Indications. — In  this  country  the  most  usual  indication  for  accouche- 
ment force  is  threatened  or  actual  eclampsia.  Occasionally  it  becomes  neces- 
sary in  concealed  or  accidental  ruemorrnage,  and  also  in  the  rare  cases  of 
acute  oedema  of  the  lungs,  or  broken  cardiac  compensation  complicating 
pregnancy,  as  well  as  irTeertain  cases  of  placenta  praevia. 

Methods. — If  labour  has  already  begun  and  the  upper  portion  of  the 
cervical  canal  is  obliterated,  most  excellent  results  are  obtained  by  the 


Fi&.  324. — Diagrams  illustrating  Manual  Dilatation  of  Cervix  (Harris). 

method  of  manual  dilatation  suggested  by  Philander  A.  Harris.  But  if 
labour  has  not  set  in,  and  the  cervix  is  hard  and  rigid,  the  operation  may  be 
extremely  difficult;  and  if  dilatation  be  effected  by  brute  force  it  is  frequent- 
ly accompanied  by  deep  tears  through  the  cervix,  and  occasionally  through 
the  lower  uterine  segment,  which  may  lead  to  the  death  of  the  patient  from 
haemorrhage  or  infection. 

Generally. speaking,  if  the  index  finger  can  be  carried  through  the  inter- 
nal os,  dilatation  can  be  readily  accomplished  by  this  method.  Moreover, 
if  the  cervical  canal  is  soft  and  yielding,  although  too  narrow  to  admit  the 
finger,  the  first  stage  of  dilatation  may  be  effected  by  means  of  a  steel  dilator 
and  completed  by  Harris's  method.  On  the  other  hand,  if  the  cervix  be  car- 
tilaginous in  consistency,  or  instrumental  dilatation  proves  more  difficult 
than  was  expected,  the  operation  should  be  abandoned  as  presenting  more 
danger  than  does  expectant  treatment. 

At  the  time  of  operation,  the  patient  should  be  profoundly  anaesthetized 


ACCOUCHEMENT  FORCE  349 

and  tin'  aseptic-  technique  most  rigorous.  The  danger  of  contamination 
from  the  faeces  can  be  minimized  by  moving  the  bowels  freely  by  means 
of  a  rectal  enema.,  and  then  applying  over  the  anus  a  sterile  towel,  which 
is  held  in  place  by  strips  of  adhesive  plaster  until  the  completion  of  the 
various  manipulations.  One  hand,  thoroughly  anointed  with  sterile  vase- 
line, is  then  introduced  into  the  vagina,  and  the  index  finger  carried  up  the 
cervical  canal  and  slowly  forced  through  the  internal  os,  after  which  the  tips 
of  the  index  and  second  fingers  are  passed  into  the  cervical  canal,  gradually 
dilating  it  as  well  as  the  internal  os.  When  this  has  heen  accomplished, 
completion  of  the  dilatation  is  usually  comparatively  easy.  The  thumb  is 
pushed  past  the  index  linger  with  much  the  same  motion  as  is  employed  in 
snapping  one's  fingers;  then,  as  dilatation  progresses,  past  two,  three,  and 
finally  all  four  fingers.    These  manoeuvres  are  clearly  shown  in  Fig.  32-i. 

"When  the  internal  os  is  obliterated,  complete  dilatation  of  the  cervix 
can  be  effected  in  a  very  few  minutes  by  Harris's  method,  and  in  appro- 
priate cases  when  the  internal  os  will  admit  only  the  tip  of  the  index  finger, 
satisfactory  results  can  usually  be  obtained  within  half  an  hour.  Per- 
sonally I  have  found  this  method  very  effective,  and  am  able  to  confirm  all 
that  Harris  has  claimed  for  it.  It  would  certainly  seem  to  be  far  superior 
to  the  procedures  advocated  by  Edgar  and  Bonnaire,  in  which  both  hands 
are  employed  simultaneously.  Furthermore,  since  they  come  into  intimate 
contact  with  the  anus,  the  risk 
of  infection  from  the  rectal  con- 
tent s  is  greatly  increased. 

Various  instruments  have 
been  devised  to  effect  the  rapid 
and  complete  dilatation  of  the 
cervical  canal,  but  none  of  these  FlG  S25._Eeto0LD8,s  cervical  Dilatob. 

are  as  satisfactory  as  manual  dila- 
tation.    Occasionally,  when  the  cervical  canal  is  completely  obliterated, 
and  the  resistance  is  offered  only  by  the  external  os,  excellent  results  may 
be  obtained  with  Reynolds's  instrument. 

AYhen  rapid  delivery  is  urgently  indicated,  Diihrssen  recommends  that 
deep  incisions  be  made  through  several  portions  of  the  cervical  canal,  which 
are  united  by  sutures  after  the  completion  of  labour.  This  manipulation, 
however,  requires  considerable  surgical  skill,  and  is  not  to  be  recom- 
mended save  under  exceptional  circumstances.  It  is  occasionally  indicated 
in  concealed  haemorrhage,  when  prompt  evacuation  of  the  uterine  contents 
is  imperative  in  order  to  save  the  life  of  the  patient,  in  whom  the  consistence 
of  the  cervix  is  such  that  rapid  manual  or  instrumental  dilatation  appears 
impossible.  Under  other  conditions,  however,  it  cannot  be  looked  upon  as 
a  justifiable  procedure,  a  remark  which  also  applies  to  Diihrssen's  so-called 
vaginal  Cesarean  section. 

LITERATURE 

Ahlfelp.     118  Falle  von  Einleitung  der  kiinstlichen  Friihgeburt.     Centralb.  f.  Gyn., 
1S00.  529-534. 
Lehrbuch  der  Geburtshiilfe,  II.  Aufl.,  1898,  498. 


350  OBSTETRICS 

Bab.     Contribution  a  l'etude  des  indications  de  l'accouchement  premature  artificiel,  etc. 

L'Obstetrique,  1899,  iv,  471. 
Lecons  de  pathologie  obstetricale.     Paris,  1900. 
Bonnaire.     Tarnier  et  Budin,  Traite  de  l'art  des  accouchements,  1901,  t.  iv,  444. 
Brouardel.     L'avortement.     Paris,  1901. 
Calderini.    See  Parvin. 
Champetier  de  Ribes.     De  l'accouchement  provoque.     Annales  de  gyn.  et  d'obst.,  1888, 

xxx,  401-438. 
Davis.     Puerperal  Pernicious  Anaemia.     Trans.  Amer.  Gyn.  Soc,  1891,  xviii,  173. 
Denman.     An  Introduction  to  the  Practice  of  Midwifery.     7th  ed.,  London,  1823,  318. 
Dohrn.     See  Parvin. 
D'Outrepont.     Beobachtungen  u.  Bemerkungen.     Gemeinsame   Zeitschr.  f.   Geburtsk., 

1828,  ii,  549. 
Duhrssen.     Ueber  den  Werth  der  tiefen  Cervix-  und  Scheiden-Damm  Einschnitte  in 

der  Geburtshiilfe.     Archiv  f.  Gyn.,  1890,  xxxvii,  27-66. 
Ueber  vaginalen  Kaiserschnitt.     Volkmann's  Sammlung  klin.  Vortrage,  N.  F.,  Nr.  232. 
Edgar.     Methods  and  Aids  in  Obstetric  Teaching.     N.  Y.  Med.  Jour.,  1896,  November 

14th,  21st,  28th,  and  December  5th. 
Fehling.     Ein  Fall  von  Chorea  gravidarum.     Archiv  f.  Gyn.,  1874,  vi,  137-139. 
Fieux.     Procedes  de  provocation  et  de  la  terminaison  artificielle  rapide  de  l'accouche- 

ment.     Annales  d'obst.  et  de  gyn.,  1901,  lv,  409-450. 
Graefe.     Ueber  den  Zusammenhang  der  perniciosen  Anaemie  mit  der  Graviditas.     D.  I., 

Halle,  1880. 
Guillemeau.     De  1'heureux  accouchement  des  femmes.     Paris,  1594. 
Harris.    A  Method  of  performing  Rapid  Dilatation  of  the  Os  Uteri,  etc.     Amer.  Jour. 

Obst.,  1894,  xxix,  37-49. 
Kleinwachter.     Die  kunstliche  Unterbrechung  der  Schwangerschaft,  III.  Aufl.,  1902. 
Krause.     Die  kunstliche  Friihgeburt.    Breslau,  1855. 
Leopold  (Buschbeck).     Beitrag  zur  kiinstl.  Friihgeburt  wegen  Beckenenge.     Arbeiten 

aus  der  konigl.  Frauenklinik  in  Dresden,  1893,  i,  93-123.     See  Parvin. 
Leopold  (Sehoedel).    Erfahrungen   liber  kunstliche    Friihgeburten,   eingeleitet  wegen 

Beckenenge.    Archiv  f.  Gyn.,  1901,  lxiv,  151-164. 
Lepage  et  Sainton.     Accouchement  provoque  pour  un  cas  de  nevrite  peripherique  alco- 

holique.     Comptes  rendus  de  la  Soc.  d'Obst.,  de  Gyn.  et  de  Psed.  de  Paris,  1901,  iii, 

93-99. 
Levin  und  Brenning.     Die  Fruchtabtreibung  durch  Gifte.     Berlin,  1899. 
Lohlein.     See  Parvin. 
Macan.     See  Parvin. 

Mauriceau.     Traite  des  maladies  des  femmes  grosses,  etc.    6me  ed.,  1721,  161. 
Parvin  et  al.     Artificial  Premature  Labour,  its  Indications  and  Methods.    Verh.  des  X. 

Internat.  med.  Congresses,  Berlin,  1891,  Bd.  iii,  Abtheilung,  viii,  107-149. 
Pelzer.     Ueber  Einleitung  der  kiinstlichen  Friihgeburt.     Centralbl.  f.  Gyn.,  1892,  35-36. 
Pfannenstiel.     Ueber  die  Gefahrlichkeit  der  intraut.  Glycerineinspritzung.     Centralbl. 

f.  Gyn.,  1894,  xxix,  37-49. 
Pinard.     De  l'accouchement  provoque.    Annales  de  Gyn.  et  d'Obst.,  1891,  xxxv,  1-16, 

81-112. 
Indication  de  l'operation  Cesarienne  considered  en  rapport  avec  celle  de  la  symphyse- 

otomie  et  de  l'accouchement  premature  artificiel.     Annales  de  Gyn.  et  d'Obst.,  1899, 

Iii,  81-117. 
Sanger.    See  Parvin. 
Siegemundin.     Die  konigl.  preussische  und  Chur-Brandenb.  Hof-Wehe-Mutter.     Berlin, 

1756,  216. 


CHAPTER   XX 


FORCEPS 


The  obstetrical  forceps  is  an  instrument  designed  for  the  extraction, 
under  certain  conditions,  of  the  child  when  it  presents  by  the  head.  It 
consists  of  two  branches  which  cross  one  another,  being  designated  re- 
spectively right  and  left,  according  to  the  side  of  the  pelvis  to  which  each 
corresponds.  They  are  introduced  separately  into  the  genital  canal  and 
are  articulated  after  being  placed  in  position.  Each  branch  is  made  up  of 
four  portions — the  handle,  blade,  shank,  and  lock. 

The  instruments  vary  considerably  in  size  and  shape,  as  will  be  seen 
when  certain  varieties  of  forceps  are  considered.  The  blades  possess  a 
double  curvature — the  cephalic  and  the  pelvic — the  former  being  adapted  to 
the  shape  of  the  child's  head,  the  latter  to  that  of  the  birth  canal.  The 
blades  are  more  or  less  elliptical  in  shape,  tapering  towards  the  shank,  and 
are  usually  fenestrated  so  as  to  allow  of  a  firm  hold  upon  the  head.  Certain 
authorities,  however,  pre- 
fer solid  blades  in  the  be- 
lief that  they  can  be  made 
less  bulky. 

The  cephalic  curves 
should  be  such  as  to  per- 
mit the  head  to  be  grasped 
firmly  but  without  serious 
compression.  The  great- 
est distance  between  the 
two  blades  should  not  ex- 
ceed 7.5  centimetres  (3 
inches)    when    they    are 

articulated.  The  pelvic  curve  corresponds  more  or  less  to  the  axis  of  the 
birth  canal,  but  varies  considerably  in  different  instruments.  TVhen  the 
forceps  is  placed  upon  a  plane  surface,  the  tips  of  the  blades  should  be 
about  8.8  centimetres  (3£  inches)  higher  than  the  handles.  The  latter  are 
connected  with  the  blades  by  the  shanks,  which  give  the  requisite  length  to 
the  instrument. 

The  two  branches  articulate  at  the  lock,  which  varies  widely  in  different 
instruments.  The  English  type  consists  of  a  socket  upon  each  branch,  into 
which  fits  the  shank  of  the  other  half  of  the  instrument.     This  arrange- 

351 


Fig.  326. — Simpson's  Forceps,  Cephalic  Cukve. 


Fig.  327. — Simpson's  Forceps,  Pelvic  Curve. 


352 


OBSTETRICS 


ment  permits  of  ready  articulation,  but  does  not  hold  the  blades  firmly  to- 
gether. In  the  French  lock  a  pivot  is  screwed  into  the  shank  of  the  left 
branch,  while  the  right  presents  an  opening  which  can  be  adjusted  to  it, 
the  screw  being  tightened  after  articulation.  The  German  lock  is  a  com- 
bination of  the  two,  the  shank  of  the  left  branch  bearing  a  pivot  with  a 
broad,  flat  head,  while  the  right  is  provided  with  a  notch  which  corre- 
sponds to  the  pivot.  When  the  instrument  is 
properly  articulated  the  handles  should  fall 
together  in  such  a  way  as  to  be  convenient- 
ly grasped  by  the  operator  with  one  hand. 


Fig.  328. — Lock  of  English  Forceps. 


Fig.  329. — Lock  of  French  Forceps. 


History. — Crude  forceps  were  in  use  from  an  early  period,  several 
varieties  having  been  described  by  Albucasis^who  died  in  1112;  but  as  their 
inner  surfaces  were  provided  with  teeth  intended  to  penetrate  the  head,  it 
is  evident  that  they  were  intended  for  use  only  upon  dead  children. 

The  true  obstetrical  forceps  was  devised  in  the  latter  part  of  the  six- 
teenth or  the  beginning  of  the  seventeenth  century  by  a  member  of  the 
Chamberlen  family.  The  invention,  however,  was  not  made  public  at  the 
time,  but  was  preserved  as  a  family  secret  through  four  generations,  and  did 
not  become  generally  known  until  the  early  part  of  the  eighteenth  century. 
Prior  to  that  time  version  had  been  the  only  method  which  permitted  the 
artificial  delivery  of  an  unmutilated  child,  and,  accordingly,  when  that 
operation  was  out  of  the  question  and  delivery  became  imperative,  it  could 
be  accomplished  only  by  the  destruction  of  the  child,  when  delivery  was 
effected  by  means  of  hooks  and  crotchets.  Thus,  before  the  invention  of 
forceps,  the  use  of  instruments  was  synonymous  with  the  death  of  the  child, 
and  frequently  of  the  mother  also,  and  tended  to  bring  obstetrics  into 
disrepute. 

William  Chamberlen,  the  founder  of  the  family,  was  a  French  physi- 
cian, who  fled  from  France  as  a  Huguenot  refugee  and  landed  at  Southamp- 
ton in  1569.  He  died  in  1596,  leaving  a  large  family.  Two  of  his  sons, 
both  of  whom  were  named  Peter,  and  designated  as  the  elder  and  younger 
respectively,  studied  medicine  and  settled  in  London.  They  soon  became 
successful  practitioners,  and  devoted  a  large  part  of  their  attention  to  mid- 
wifery, in  which  they  became  very  proficient.  They  attempted  to  con- 
trol the  instruction  of  midwives,  and  in  justification  of  their  pretensions 
claimed  that  they  could  successfully  deliver  patients  when  all  others  had 
failed. 

The  younger  Peter  died  in  1626  and  the  elder  in  1631.     The  latter 


FORCEPS  353 

left  lit )  male  children,  bill  the  former  was  survived  by  several  sons,  one  of 
whom,  born  in  L601,  was  likewise  named  Peter.  To  distinguish  him  from 
his  father  and  uncle,  he  is  usually  spoken  of  as  \)v.  Peter,  as  the  other  two 
did  noi  possess  that  title,  lie  was  well  educated,  having  studied  at  Cam- 
bridge, Eeidelberg,  and  Padua,  and  on  his  return  to  London  was  elected 
a  Fellow  of  the  Royal  ( lollege  of  Physicians.  He  was  most  successful  in  the 
practice  of  his  profession,  and  couidcd  among  his  clients  many  of  tin: 
royal  family  and  nobility.  Like  his  father  and  uncle,  he  attempted  to 
monopolize  the  control  of  the  midwives,  but  his  pretensions  were  set  aside 
by  the  authorities.  These  attempts  gave  rise  to  a  great  deal  of  discussion, 
and  many  pamphlets  were  written  as  to  the  morality  of  women  in  labour 
being  attended  by  men,  which  he  answered  in  a  paper  entitled  "  A  Voice  in 
Ramah,  or  the  Cry  of  Women  and  Children  as  echoed  Forth  in  the  Com- 
passions of  Peter  Chamberlen."  Tie  was  a  man  of  considerable  ability,  and 
united  at  the  same  time  some  of  the  virtues  of  a  religious  enthusiast  with 
many  of  the  devious  qualities  of  a  quack.  He  died  at  Woodham,  Mortimer 
Hall,  Essex,  in  1683,  the  place  remaining  in  the  possession  of  his  family 
until  well  into  the  succeeding  century.  Formerly  he  was  considered  the 
inventor  of  the  forceps,  but,  as  we  now  know,  this  view  was  incorrect. 

He  left  a  very  large  family,  and  three  of  his  sons — Hugh,  Paul,  and 
John — became  physicians,  and  devoted  special  attention  to  the  practice  of 
midwifery.  Of  these  Hugh  (1630-1706)  was  the  most  important  and  in- 
fluential. Like  his  father,  he  possessed  considerable  ability,  and  at  the 
same  time  took  a  practical  interest  in  politics.  Some  of  his  views  not  being 
in  favour,  he  was  forced  to  leave  England,  and  while  in  Paris  in  1673  at- 
tempted to  sell  the  family  secret  to  Mauriceau  for  10,000  livres,  claiming 
that  by  its  means  he  could  deliver  in  a  very  few  minutes  the  most  difficult 
cases.  Mauriceau  placed  at  his  disposal  a  rhachitic  dwarf  whom  he  had  been 
unable  to  deliver,  and  Chamberlen,  after  several  hours  of  strenuous  effort, 
was  likewise  obliged  to  acknowledge  his  inability  to  do  so.  Notwithstand- 
ing his  failure,  however,  he  maintained  friendly  relations  with  Mauriceau, 
and  on  returning  home  translated  the  latter's  book  into  English.  In  his 
preface  he  refers  to  the  forceps  in  the  following  words:  "My  father, 
brothers,  and  myself  (though  none  else  in  Europe  as  I  know)  have  by 
God's  blessing  and  our  own  industry  attained  to  and  long  practised  a  way 
to  deliver  women  in  this  case  without  prejudice  to  them  or  their  infants." 

Some  years  later  he  went  to  Holland  and  sold  his  secret  to  Roonhuysen. 
Shortly  afterward  the  Medico-Pharmaceutical  College  of  Amsterdam  was 
given  the  sole  privilege  of  licensing  physicians  to  practise  in  Holland,  to 
each  of  whom,  under  pledge  of  secrecy,  was  sold  Chamberlen's  invention 
for  a  large  sum.  This  practice  continued  for  a  number  of  years,  until 
Yischer  and  Aran  der  Poll  purchased  the  secret  and  made  it  public,  when  it 
was  found  that  the  device  consisted  of  one  blade  only  of  the  forceps. 
Whether  this  was  all  that  Chamberlen  sold  to  Roonhuysen,  or  whether  the 
Medico-Pharmaceutical  College  had  swindled  the  purchasers  of  the  secret, 
is  not  known. 

Hugh  Chamberlen  left  a  considerable  family,  and  one  of  his  sons — 
Hugh  (1661-1728) — practised  medicine.     He  was  a  highly  educated,  Te- 


354 


OBSTETRICS 


spected,  and  philanthropic  physician,  and  numbered  among  his  clients 
members  of  the  best  families  in  England.  He  was  an  intimate  friend  of 
the  Duke  of  Buckingham,  and  when  he  died  the  latter  caused  a  statue  to  be 
erected  in  his  honour  in  Westminster  Abbey.  During  the  later  years  of  his 
life  he  allowed  the  family  secret  to  leak  out,  and  the  instrument  soon  came 
into  general  use. 

For  more  than  one  hundred  years  it  was  believed  that  the  forceps 
was  the  invention  of  Dr.  Peter  Chamberlen,  but  in  the  year  1813  Mrs. 

Ivembell,  the  house- 
keeper of  a  rich  brew- 
er who  had  purchased 
Dr.  Peter  Chamber- 
len's  country  house, 
found  in  the  garret  a 
trunk  containing  nu- 
merous letters"  and  in- 
struments, among  the 
latter  being  four  pairs 
of  forceps,  together 
with  several  levers  and 
fillets.  As  is  evident 
from  the  drawings, 
the  forceps  were  in 
different  stages  of  de- 
velopment, one  pair 
being  hardly  applicable  to  the  living  woman,  while  the  others  were  useful 
instruments.  Aveling,  who  has  carefully  investigated  the  matter,  believes 
that  the  three  pairs  of  available  forceps  were  used  respectively  by  the  three 
Peters,  and  that  in  all  probability  the  first  was  devised  by  the  elder  Peter, 
son  of  the  original  William.  Probability  is  lent  to  this  view  by  the  fact  that 
Dr.  Peter,  on  one  occasion,  at  least,  spoke  of  the  invention  of  his  uncle. 
Sanger  and  Budin,  who  have  also  investigated  the  subject,  incline  to  the 
same  belief. 

The  forceps  came  into  general  employment  in  England  during  the  life- 
time of  Hugh  Chamberlen,  the  younger.  The  instrument  was  used  by 
Drinkwater,  who  died  in  1728,  and  was  well  known  to  Chapman  and  Gif- 
fard.  The  former,  writing  in  1733,  says:  "The  secret  mentioned  by  Dr. 
Chamberlen  was  the  use  of  the 
forceps,  now  well  known  by 
all  the  principal  men  of  the 
profession,  both  in  town  and 
country." 

In    1723,    Palfyn,    a    physi-  Fig.  SPA.— Palfyx's  Forceps. 

cian  of  Ghent,  exhibited  before 

the  Paris  Academy  of  Medicine  a  forceps  which  he  designated  as  mains  de 
fer.  It  was  crude  in  shape  and  did  not  articulate.  In  the  discussion  follow- 
ing its  presentation  De  la  Motte  stated  that  it  would  be  impossible  to  apply  it 
to  the  living  woman,  and  added  that  if  by  chance  any  one  should  happen  to 


Fig.  330. — Chaiiberlex's  Forceps. 


FORCEPS 


>.>.) 


Fig.  232. — Smellie's  Shout  Forceps. 


Fig.  333. — Short  Forceps. 


invent  an  instrumenl  which  could  be  so  used,  and  keep  it  secret  for  his 
own  profit,  he  deserved  to  be  exposed  upon  a  barren  rock  and  have  his 
vitals  plucked  out  by  vultures,  little  knowing  that  at  the  time  he  spoke 
an  instrumenl  had  been  in  the  pos- 
session of  the  Chamherlen  family 
for  nearly  one  hundred  years. 

The  (  haniherlen   forceps  was  a 
>huii.   straight    instrument,   which 

po ed  only  a  cephalic  curve,  and 

is  perpetuated  in  the  short  or  low 

forceps  of  to-day.     It  was  used  exclusively,  hut  with  little  modification, 

until  the  middle  of  the  eighteenth  century,  when  Lev  ret,  in  1T4T7  and 

Smellie,  in  1751,  quite  independently  of  one  another,  added  the  pelvic 

*""  curve  and  increased  the  length  of 

the  instrument.  Levret's  forceps 
was  longer  and  possessed  a  more 
decided  pelvic  curve  than  that  of 
Smellie,  and  it  is  from  these  two 
instruments  that  the  long  forceps 
of  the  present  day  is  descended — 
the  long  French  forceps  being  the  lineal  descendant  of  the  former,  and  that 
of  Simpson  of  the  latter. 

As  soon  as  the  forceps  became  public  property  it  was  subjected  to 
various  modifications,  so  that  Mulder,  in  his  atlas  published  in  1798,  was 
able  to  give  illus- 
trations of  near- 
ly 100  varieties. 
Some  idea  of  the 
desire  to  modify 
and  improve  the 
instrument    may 

be       gained       by  Fig.  334.— Long  Ff.ex.ii   Forceps    Levret  . 

glancing  at  Wit- 

kowski's  Obstetrical  Arsenal,  in  which  are  pictured  several  hundred  for- 
ceps, which,  after  all,  constitute  only  a  small  portion  of  those  devised. 
Poullefs  interesting  monograph  contains  an  excellent  historical  sketch  of 
the  development  of  the  instrument. 

Bur.  considering  all  the  work  done,  it  is  surprising  how  little  advance 

was  made  over  the  instruments 

of    Levret    and    Smellie    until 

1877,    when    Tarnier    clearly 

enunciated    the    principle    of 

axis  traction  which  has  since 

practically  revolutionized   our 

ideas  upon  the  subject. 

The  Choice  of  Forceps. — Inasmuch  as  it  would  appear  that  nearly  every 

one  interested  in  obstetrics  has  thought  it  necessary  to  attempt  to  'modify 

the  forceps  and  to  have  an  instrument  bearing  his  own  name,  the  voung 

■24 


Fig.  335. — Smellie's  Long  Forceps. 


356  OBSTETRICS 

physician  is  likely  to  be  embarrassed  by  the  multitude  from  which  he  has 
to  choose.  Any  properly  shaped  instrument  will  give  satisfactory  results 
provided  it  be  used  intelligently,  but  for  general  purposes  the  ordinary 
Simpson  forceps  is  probably  the  best,  though,  if  one  expects  to  do  much 
obstetrical  work,  a  Tarnier  axis-traction  forceps  becomes  essential.  Per- 
sonally I  always  employ  the  latter,  using  the  traction  rods  or  not,  according 
to  circumstances,  as  I  believe  it  better  to  become  thoroughly  familiar  with 
one  instrument  than  to  have  several  for  use  under  different  conditions. 

The  forceps  should  be  entirely  of  metal,  so  that  it  can  be  readily  steril- 
ized by  boiling. 

Functions  of  the  Forceps. — This  subject  has  been  considered  in  detail 
by  Chassagny.  The  forceps  may  be  used  as  a  tractor,  rotator,  compressor, 
dilator,  lever,  or  irritator. 

Its  most  important  function  is  traction  exercised  for  the  purpose  of 
drawing  the  head  through  the  genital  tract.  In  not  a  few  cases,  however, 
particularly  in  occipito-posterior  presentations,  its  employment  as -a  rota- 
tor is  attended  by  most  happy  results.  It  should  never  be  used  primarily 
as  a  compressor,  though  of  course  it  is  impossible  to  make  traction  without 
subjecting  the  head  to  a  slight  degree  of  compression;  but  when  it  is  desired 
to  bring  about  a  diminution  in  its  size  other  instruments  are  more  appro- 
priate. 

Many  authors,  especially  in  this  country,  advocate  applying  the  forceps 
through  a  partially  obliterated  cervix,  and  assisting  dilatation  by  traction 
upon  the  head.  Such  a  procedure,  however,  is  unjustifiable,  for  when  it 
becomes  necessary  to  deliver  the  child  under  such  conditions,  the  cervix 
should  be  stretched  manually,  and  forceps  not  applied  until  dilatation  is 
complete. 

In  rare  instances,  one  blade  of  the  forceps  may  be  employed  as  a  lever, 
although  at  present  use  is  very  seldom  made  of  this  function.  Formerly 
great  stress  was  laid  on  the  so-called  dynamic  action  of  the  forceps,  by 
which  is  meant  the  irritation  of  the  uterus  which  follows  its  introduction. 
Before  the  employment  of  anaesthetics,  this  function  was  of  considerable 
importance  in  operative  cases,  but  at  the  present  day  it  possesses  but  little 
'significance. 

Indications  for  the  Use  of  Forceps. — Strictly  speaking,  the  termination 
of  labour  by  forceps,  provided  it  can  be  accomplished  without  too  great 
danger,  is  indicated  in  any  condition  which  threatens  the  life  of  the  mother 
.or  _chijd.  On  the  part  of  the  mother,  such  conditions  are  eclampsia, Tieart 
lesions  attended  by  broken  compensation,  acute  oedema  of  thelungs,  haemor- 
rhage from  premature  separation  of  the  placenta,  intrapartum  infection,  or 
exhaustion.  Whenever  there  is  question  of  interference  for  the  last-named 
condition,  definite  objective  symptoms  should  be  present,  the  condition  of 
the  pulse  being  of  especial  importance;  whereas,  on  the  other  hand,  but  little 
weight  should  be  attached  to  the  statements  of  the  patient. 

As  regards  the  child,  the  operation  may  be  called  for  by  prolapse  of  the 
umbilical  cord,  premature  separation  of  the  placenta,  undue  pressure  exerted 
upon  the  head,  and  especially  by  changes  in  the  rhythm  of  its  heart-beai 
and  the  escape  of  meconium  in  vertex  presentations.    A  foetal  pulse  falling 


FORCEPS  35 


below  100,  or  exceeding  160  to  the  minute,  Indicates  that  the  child  i>  in 
danger  and  will  perish  if  qo1  promptly  delivered.  In  vertex  presentations 
the  discharge  of  amniotic  fluid  tinged  with  meconium  indicates  interference 
with  the  placental  circulation  and  imperfecl  oxygenation,  manifesting  itself 
by  paralysis  of  the  sphincter  ani.  In  breech  presentations,  od  the  other 
hand,  the  presence  of  meconium  is  without  significance,  being  due  merely 
to  pressure  exerted  upon  the  child's  abdomen. 

In  practice,  however,  the  maternal  indications  for  the  use  of  forceps 
may  be  considerably  extended,  and  in  many  instances  the  operation  may 
In'  advisable  in  the  case  of  women  suffering  from  acute  infectious  diseases, 
heart  lesions,  and  diseases^)!'  the  respiratory  tract,  who  must  be  saved  as 
far  as  possible  from  the  exhaustion  incident  to  an  unaided  second  stage 
of  labour.  Occasionally  also  it  ma}'  appear  wise  to  relieve  the  strain  upon 
a  cicatrix  resulting  from  a  recent  abdominal  section. 

One  of  the  most  frequent  indications  for  the  operation  is  afforded  by 
faulty  contraction  of  the  uterine  or  abdominal  muscles,  the  forceps  being 
utilized  merely  to  re-enforce  the  insufficient  vis-a-tergo.  In  occasional  in- 
stances, particularly  in  elderly  primiparse,  the  resistance  offered  by  the 
perinseum  and  the  vaginal  outlet  may  be  so  great  as  to  oppose  a  serious 
obstacle  to  the  passage  of  the  child,  even  when  the  expulsive  forces  are 
normal.  In  uncomplicated  cases  it  is  a  good  practical  rule  to  apply  forceps 
if  advance  does  not  occur  after  two  hours  of  satisfactory  second  stage  pains. 
but  if  the  head  is  upon  the  perina?um  and  no  progress  has  been  made  for 
one  hour  in  spite  of  good  pains,  it  is  usually  not  advisable  to  wait  much 
longer.  At  the  same  time  it  must  be  insisted  upon  that  the  operation  should 
never  be  performed  to  save  the  physician's  time,  but  only  when  distinctly 
indicated  by  the  condition  of  the  mother  or  child. 

The  following  conditions  must  be  fulfilled  before  forceps  can  be  applied 
with  safety:  (1)  The  child  must  present  correctly:  (2)  the  cervix  must  be 
fully  dilated  or  dilatable:  (3)  the  membranes  must  be  ruptured;  (4)  the 
head  of  the  child  must  be  neither  too  large  nor  too  small;  and  (5)  the 
pelvis  must  not  be  contracted. 

The  child  should  present  by  the  vertex  or  face,  and  an  accurate  diag- 
nosis be  made  as  to  the  position  and  variety,  forceps  not  being  available 
when  the  chin  is  directly  posterior.  The  forceps  is  not  applicable  to 
transverse  or  shoulder  presentations,  nor  is  it  intended  to  be  applied  to 
the  breech.  It  should  not  be  employed  in  brow  cases  until  after  conversion 
into  a  vertex  or  face  presentation  has  been  brought  about. 

The  cervix  must  always  be  completely  dilated  before  the  application  of 
forceps,  offering  a  diameter  of  from  9  to  10  centimetres.  Of  course  it  is 
possible  to  apply  the  blades  through  a  canal  measuring  only  4  or  5  centi- 
metres, but  under  such  circumstances  the  cervical  ring  offers  marked  re- 
sistance, and  if  the  head  be  dragged  through  it  by  brute  force  deep  tears 
may  result,  which  may  implicate  not  only  the  cervix  but  also  the  lower 
uterine  segment.  Even  if  only  gentle  traction  is  made,  the  practice  is  not 
to  be  recommended,  as  it  is  difficult  to  know  exactly  when  the  cervix  has 
become  sufficiently  wide  to  permit  the  passage  of  the  head,  and  the  operator 
is  prone  to  attempt  delivery  before  complete  dilatation.     Accordingly,  if 


358  OBSTETRICS 

prompt  delivery  becomes  imperative  when  the  cervix  is  only  partially 
dilated,  its  complete  dilatation  should  be  effected  manually  by  Harris's 
method,  after  which  delivery  may  be  accomplished  with  forceps  if  the  head 
is  deeply  engaged.  On  the  other  hand,  if  it  is  only  partially  engaged,  or  is 
floating  above  the  superior  strait,  delivery  is  best  effected  after  podalic  ver- 
sion. 

The  membranes  should  always  be  ruptured  before  applying  forceps,  as 
the  instrument  is  intended  to  be  applied  directly  to  the  child's  head.    If  the  ^> 
[membranes  intervene,  the  grasp  is  not  so  firm,  and,  what  is  still  more  im-  jy 
Iportant,  traction  upon  them  may  bring  about  premature  separation  of  the  3) 
'placenta. 

Before  applying  forceps,  particularly  when  engagement  has  not  yet 
occurred,  the  size  of  the  head  should  be  determined  as  accurately  as  pos- 
sible, for  if  it  be  unduly  large,  as  in  an  excessively  developed  or  hydro- 
cephalic child,  it  cannot  pass  the  superior  strait.  On  the  other  hand,  if 
it  be  abnormally  small,  it  cannot  be  properly  grasped,  since  the  blades 
will  slip  off  when  traction  is  made.  Accordingly,  the  employment  of  for- 
ceps is  contra-indicated  when  the  foetus  is  premature  or  maceraied. 

U-eneralty  speaking,  contracted  pelves  present  an  absolute  contra- 
indication to  the  application  of  forceps;  for  if  the  contraction  be  marked  it 
will  be  impossible  to  drag  the  head  through  the  pelvis,  and  if  brute  force  be 
employed  it  will  result  in  the  death  of  the  child  and  severe  injuries  to 
the  soft  parts  of  the  mother,  and  occasionally  cause  her  death.  On  the 
other  hand,  when  the  contraction  is  but_sjighl.  and  especially  when  the  head 
is  firmly  engaged  in  the  upper  part  of  the  pelvic  cavity,  the  tentative  ap- 
plication of  forceps  may  be  justifiable.  Under  such  circumstances  a  few 
tractions  of  moderate  intensity  sTRmld  be  made;  if  the  head  follows  them 
they  should  be  continued,  but  if  not  the  forceps  should  be  removed  and 
delivery  effected  in  some  other  manner. 

Preparations  for  Operation. — When  the  application  of  forceps  becomes 
necessary,  either  in  the  interests  of  the  mother  or  child,  the  physician 
should  so  inform  a  responsible  member  of  the  family.     It  is  usually  not 


Fig.  336. 
Eobb's  Leg-Holdee. 


advisable  to  consult  the  patient  upon  the  subject,  as  she  is  not  in  a  con- 
dition to  make  an  intelligent  decision. 

If  the  operation  promises  to  be  easy  it  may  be  performed  upon  the  bed, 
but  in  all  other  cases,  whenever  possible,  the  patient  shotild  be  placed  upon 
a  table  of  suitable  height.     Anaesthesia  should  always  be  employed,  and 


FORCEPS 


359 


Fig.  337. 


-dlagbam  showing  position  of  head  ix 
Various  Forceps  Operations. 


whenever  practicable  its  administration  should  be  intrusted  to  a  com- 
petent  assistant,  rather  than  to  the  uurse  or  some  member  of  the  family, 
since  in  the  latter  case  a  Large  part  of  the  obstetrician's  attention  mus1 
of  necessity  be  devoted  to  watching  the  general  condition  instead  of  being 
concentrated  upon  the  operation. 

When  anaesthesia  is  complete,  the  patient's  buttocks  should  be  brought 
to  llu1  edge  of  the  bed  or  table,  and  her  legs  held  in  position  by  an  appro- 
priate leg-holder,  which  is 
particularly  convenient,  in 
private  practice,  as  it  en- 
ables one  to  dispense  with 
assistants  for  holding  the 
legs.  After  the  pubic  hairs 
have  been  shaved,  the  geni- 
talia should  be  thoroughly 
washed  with  soap  and  hot 
water,  bathed  with  alcohol, 
and  thoroughly  soaked  in  a 
l-to-1,000  bichloride  solu- 
tion. Disinfection  of  the  va- 
gina is  not  necessary  unless 
the  patient  is  infected  or  has 
been  subjected  to  previous  at- 
tempts at  delivery.  The  legs 
and  body  should  be  covered 

with  sterile  towels  in  such  a  manner  as  to  leave  only  the  genitalia  exposed, 
special  attention  being  given  to  covering  the  anus  so  as  to  prevent  contami- 
nation from  the  fasces.     (See  Figs.  317  and  318.) 

If  the  outlet  be  small  and  rigid,  it  is  advisable  to  dilate  it  by  means  of 
the  hand  before  beginning  the  operation.  For  this  purpose  the  fingers, 
anointed  with  sterile  vaseline,  are  arranged  in  the  form  of  a  cone,  and 
with  a  rotary  motion  slowly  introduced  through  the  vulva  until  the  entire 
hand  can  readily  be  carried  up  into  the  vagina. 

Application  of  Forceps. — Forceps  operations  are  designated  as  low,  mid, 
high,  and  floating,  according  to  the  position  of  the  head.  When  the  pre- 
senting part'  rest's  upon  the  perinseum,  or  lies  below  the  line  joining  the 
ischial  spines,  we  speak  of  low  forceps;  when  it  presents  at  or  just  above  the 
ischial  spines,  mid  forceps;  when  the  head  has  partially  descended  into  the 
pelvic  canal,  but  its  greatest  circumference  has  not  passed  the  superior 
strait,  high  forceps;  and  when  it  is  freely  movable  above  the  pelvic  brim 
the  operation  is  termed  forceps  upon  the  floating  head. 

The  low  forceps  operation  usually  offers  but  little  difficulty,  and  may 
be  undertaken  upon  comparatively  slight  indications.  The  mid  operation 
is  more  difficult,  but  not  often  excessively  so.  On  the  other  hand,  the  high 
operation  is  always  difficult,  and  should  not  be  attempted  unless  im- 
peratively demanded  by  the  condition  of  the  mother  or  child.  Forceps 
upon  the  floating  head  is  a  most  serious  procedure,  and  is  very  rarely 
indicated.    Generally  speaking,  the  fact  that  the  head  is  not  engaged  indi- 


360 


OBSTETRICS 


Fig.  338. — Forceps  Correctly  Applied  along  Occipito- 
mental Diameter,  Pelvic  Curve  towards  Occiput. 


cates  some  disproportion  between  it  and  the  superior  strait,  so  that  the 
operation  should  not  be  thought  of  until  accurate  information  as  to  the 

size    of    both    is 
available.      More- 
over,     in      those 
cases     in     which 
there  is  no  serious  dispro- 
portion, and   in  which   the 
operation    appears    feasible, 
delivery  can  usually  be  ac- 
complished more  safely  and 
rapidly  by  version. 

The   forceps  is   so   con- 
structed   that    its    cephalic 
curve  is  best  adapted  to  the 
sides    of    the    child's    head, 
the  bijDarietal  diameter  cor- 
responding   to    the   line    of 
greatest     distance     between 
the    blades.      The    head    is 
grasped  in  an  ideal  manner 
when  the  long  axis  of 
the  blades  corresponds 
to  the  occipito-mental  diam- 
eter, the  fenestra  including 
the  parietal  bosses  and  the 
tips  lying  over  the  cheeks, 
while  the   concave  margins 
of  the  blades  look  towards 
either   the    occiput    or    the 
face.    With  such  a  grasp  the 
forceps  obtains  a  firm  hold 
and  cannot  slip  off, 
and  traction  can  be 
made    in    the    most 
advantageous    manner. 
On   the    other   hand,    when 
the      forceps      is      applied 
obliquely    with    one    blade 
over  the  brow  and  the  other 
over   the    opposite    mastoid 
region,  the  grasp  is  less  se- 
cure,  and   the   head  is   ex- 
posed to  more  injurious  pres- 
sure.    If  one  blade  is  accu- 
rately applied  over  the  face 
and  the  other  over  the  occiput,  the  instrument  cannot  be  locked,  while  if  the 
former  is  slipped  down  so  as  to  lie  only  over  the  forehead,  the  grasp  is  very 
insecure,  and  each  traction  tends  to  extend  the  head  (see  Figs.  342  and  343). 


Fig.  339. — Forceps  Correctly  Applied  along  Occipito- 
mental Diameter,  Pelvic  Curve  towards  Face. 


Fig.  340. — Forceps  Applied  to  Face  along  Occipito- 
mental Diameter. 


FORCEPS 


361 


For  these  reasons,  then,  the  forceps  should  be  applied,  when  possible,  di- 
rectly to  the  sides  of  the  head  along  its  occipito-mental  or  jugo-parietal  diame- 
ter. This  is  known  as  the  cephalic,  in  contra-distinction  to  the  pelvic  applica- 
tion.   The  former  was  recommended  by  Smellie  and  Baudelocque,  but,  as  it 


Fig.  341. — Forceps  Applied  Obliquely  over  Brow  and  Mastoid  Region. 


Fig.  342.— Showing   that  when  One  Blade  is  Applied  oyer  Occiput  axd   Other  oyer  the 
Face,  Forceps  cannot  be  Locked. 


Fig  343.-Showtng  Extension  of  Head  when  One  Blade  is  Applied  oyer  Brow  and  Other 
oyer  Occiput,  explaining  Tendency  of  the  Instrument  to  Slip  off. 

is  more  difficult  than  the  latter,  it  fell  into  disuse,  and  was  not  generally  prac- 
tised until  Pinard,  Farabeuf  and  Varnier  demonstrated  the  inestimable  ad- 
vantages which  it  possessed  over  the  pelvic  application.    In  the  latter  the 


362 


OBSTETRICS 


left  blade  is  applied  to  the  left  and  the  right  blade  to  the  right  side  of  the 
mother's  pelvis,  no  matter  what  the  presentation,  consequently  the  head  is 
grasped  obliquely,  unless  the  sagittal  suture  is  directed  antero-posteriorly. 

An  accurate  idea  of  the  exact  position  of  the  head  is  absolutely  essential 
to  the  cephalic  application.  With  the  head  resting  upon  the  perinseum  this 
can  usually  be  obtained  by  examining  with  two  fingers;  but  when  it  is 
higher  up  an  absolute  diagnosis  can  be  made  only  by  locating  the  posterior 
ear,  Avhich  usually  necessitates  the  introduction  of  four  fingers  or  the 
entire  hand  into  the  vagina.  This,  of  course,  requires  profound  anaesthesia, 
and  is  therefore  practicable  only  just  before  introducing  the  forceps.  Ordi- 
narily, after  locating  the  ear,  the  examining  hand  is  not  removed,  but  re- 
mains in  place  to  serve  as  a  guide  for  the  introduction  of  the  first  blade, 
which  should  be  applied  over  the  posterior  ear  no  matter  whether  it  be  the 
right  or  left.  This  rule  admits  of  exception  in  two  instances  only — namely, 
when  the  head  is  resting  upon  the  perinamm,  when  the  sagittal  suture  usu- 
ally extends  antero-posteriorly,  or  when  it  is  movable  at  the  pelvic  brim. 
Faulty  diagnosis  not  infrequently  gives  rise  to  an  improper  application  of 
forceps,  and  is  one  of  the  most  frequent  factors  in  converting  what  should 
be  an  extremely  simple  procedure  into  a  serious  and  difficult  operation. 

Forceps  Delivery  with  the  Head  at  the  Vulva. — With  the  head  in  this 
position,  the  obstacle  to  delivery  is  usually  due  to  insufficient  expulsive  force 

or   to    abnormal   resistance    on    the 

r  part  of  the  perineum.     Under  such 

circumstances  the  sagittal  suture 
usually  occupies  the  antero-posterior 


S 


Fig.  344. — Low  Forceps,  Introduction  of 
Left  Blade  to  Left  Side  of  Pelvis. 


Fig.  345. — Low  Forceps,  Left  Blade  in 
Place. 


diameter  of  the  pelvic  outlet,  with  the  small  fontanelle  directed  towards 
either  the  symphysis  pubis  or  the  concavity  of  the  sacrum.    In  either  event 


I'n|;ci:i's 


363 


the    forceps^   If  applied   to   the 

sides  of  t  he  pelvis,  will  grasp  I  lie 
head  in  an  ideal  manner.  Ac- 
cordingly, the  left  Made  is  inl  ro- 
duced  to  the  It'll  and  (he  righl 
blade  in  the  righl  side  of  the 
pelvis,  the  mode  of  procedure 
being somewhai  as  follows:  Two 
fingers  of  lite  right  hand  are 
passed  into  the  left  and  poste- 
rior portion  of  the  vulva  and 
carried  up  the  vagina  to  the  re- 
gion of  the  internal  os.  The 
handle  of  the  left  branch  is  then 
seized  between  the  thumb  and 
two  fingers  of  the  left  hand — 
just  as  in  holding  a  pen — and 
the  tip  of  the  blade  is  gently 
passed  into  the  vagina  along  the 
fingers  of  the  right  hand  which 
serve  as  a  guide.  As  it  is  intro- 
duced the  handle  is  held  almost 
vertically  at  first,  but  as  the 
blade  adapts  itself  to  the  head  it 
is  depressed,  so  that  it  eventual- 
ly takes  a  horizontal  position. 
The  guiding  fingers  are  then 
withdrawn,  and  the  handle  is 
left  to  itself  or  held  by  an  assist- 
ant. In  the  same  manner,  two 
fingers  of  the  left  hand  are  then 
introduced  through  the  right 
and  posterior  portion  of  the 
vulva  to  serve  as  a  guide  for  the 
right  blade,  which  is  held  in 
the  right  hand  and  introduced 
into  the  vagina.  The  guiding 
fingers  are  now  removed  and 
all  that  remains  to  be  done  is  to 
articulate  the  branches.  Usu- 
ally they  lie  in  such  a  manner 
that  they  can  be  locked  without 
difficulty;  but  when  this  cannot 
be  done,  first  one  and  then  the 
other  blade  should  be  gently 
moved  until  they  are  brought 
into  such  a  position  as  to  be  ar- 
ticulated with  ease. 


Fig.  346. — Low  Forceps,  Left  Blade  in  Place, 
Introduction  of  Eight  Blade. 


Fig.  347. — Low  Forceps  ;  Instrument  in  Place 
and  Articulated. 


164 


OBSTETRICS 


V.' 


K 


\ 


When  this  has  been  accomplished,  an  examination  is  made  to  ascertain  I  j 
whether  the  blades  have  been  correctly  applied,  or  whether  they  inclose  J 

the  lips  ot  the  cervix.  In 
the  latter  case  the  forceps 
should  be  loosened  and  re- 
applied. When  we  are  cer- 
tain that  the  blades  are  sat- 
isfactorily placed,  the  han- 
dles are  seized  with  one 
hand  and  gentle  intermit- 
tent traction  is  made  in 
a  horizontal  direction  un- 
til the  perimeum  begins 
to  bulge.  As  soon  as  the 
vulva  becomes  distended  by 
the  occiput,  the  handles 
are  gradually  elevated  so 
that  they  come  almost  in 
contact  with  the  abdomen 
of  the  patient  as  the  parie- 
tal bosses  emerge.  During 
the  latter  manoeuvre  the  four  fingers  should  grasp  the  upper  surface  of  the 
handles  and  shanks,  while  the  thumb  up  their  lower  surface  exerts  the 
necessary  force. 


Fig.  348. — Low  Forceps  ;  Horizontal  Traction. 


Fig.  349. — Low  Forceps  : 
Upward  Traction. 


Fig.  350. — Low  Forceps; 
Extreme  Upward  Traction. 


In  delivering  the  head  nature's  method  should  be  simulated  as  closely 
as  possible.  Accordingly,  traction  should  be  made  intermittently,  the  head 
being  allowed  to  recede  in  the  intervals,  as  in  spontaneous  labour.    Except 


FORCEPS 


365 


when  urgently  indicated,  it  should  be  extracted  very  slowly,  so  as  to  give 
time  for  proper  stretching  and  dilatation  of  the  perinseum,  which  in  primip- 

arous  women  cannot  be  satisfactorily  accomplished  in  less  than  from  fifteen 
to  twenty  minutes. 

Many  authors  recommend  removing  the  forceps  as  soon  as  the  vulva 
is  distended  by  the  head,  ami  slowly  expressing  it  hy  pressure  upon  the  pos- 
terior portion  of  the 
perinamm,  in  the  be- 
lief that  hy  so  doing 
the  liability  to  perineal 
'e    is   diminished. 


Fig.  351. — Low  Forceps,  Occiput  directly 
Posterior  ;  Horizontal  Traction  (Fara- 
beuf  and  Varnier). 

possible  to  exercise  far  more  control  over  its  advance,  the  increased  disten- 
tion of  the  vulva  due  to  the  thickness  of  the  blades  being  so  slight  as  to  be 
without  practical  importance. 


Fig.  352. — Low  Forceps,  Occiput 
directly  Posterior  ;  Upward 
Traction  (Farabeuf  and  Var- 
nier). 


When  the  occiput  is  directed  posteriorly,  traction  should  be  made  in 
a  downward  direction  until  the  forehead  or  root  of  the  nose  engages  under 
the  symphysis,  after  which  the  handles  should  be  slowly  elevated,  when  the 
bregma,  followed  by  the  occiput,  slowly  emerges  over  the  anterior  margin  of 


366 


OBSTETRICS 


the  perinasum.  In  these  cases  extraction  is  more  difficult  than  when  the 
occiput  is  anterior,  and  owing  to  the  larger  circumference  of  the  head, 
which  distends  the  vulva,  is  more  liable  to  give  rise  to  perineal  tears. 

Mid  Forceps  Operations.- — When  the  head  lies  above  the  perinseum,  the 
sagittal  suture  usually  occupies  an  oblique  or  transverse  diameter  of  the 
pelvic  canal.  In  such  cases  the  forceps  should  be  applied  to  the  sides  of 
the  head.  This  is  best  accomplished  by  introducing  two  or  more  fingers 
into  the  vagina  sufficiently  deeply  to  feel  the  posterior  ear,  over  which,  no 
matter  whether  it  be  the  right  or  left,  the  first  blade  should  be  applied. 

In  left  occipitoanterior  jDositions,  the  entire  right  hand  introduced  into 
the  left  posterior  segment  of  the  pelvis  should  locate  the  posterior  ear,  and 
at  the  same  time  serve  as  a  guide  for  the  introduction  of  the  left  branch  of 
the  forceps,  which  is  held  in  the  left  hand  and  applied  over  the  posterior 


Fig.  353. — Mid  Forceps,  Hand  in  Vagina, 
seeking  Posterior  Ear. 


Fig.  354. — Mid  Forceps,  Introduction 
of  First  Blade. 


ear.  The  guide  hand  is  then  withdrawn,  when  the  handle  of  the  forceps 
may  be  held  by  an  assistant  or  left  to  itself,  as  it  will  usually  retain  its  posi- 
tion without  difficulty. 

Two  fingers  of  the  left  hand  are  then  introduced  into  the  right  and 
posterior  segment  of  the  genital  canal,  no  attempt  being  made  to  reach  the 
anterior  ear,  which  lies  in  the  neighbourhood  of  the  right  ilio-pectineal 
eminence.  The  right  branch  of  the  forceps,  held  in  the  right  hand,  is 
then  introduced  along  the  left  hand  as  a  guide.  After  its  introduction  it 
still  remains  to  apply  it  over  the  anterior  ear  of  the  child.  This  is  accom- 
plished by  gently  rotating  it  anteriorly  until  it  comes  to  lie  directly  oppo- 
site the  blade  which  was  first  introduced.  The  two  branches  being  now 
articulated,  one  blade  of  the  forceps  occupies  the  posterior  and  the 
other  the  anterior  extremity  of  the  left  oblique  diameter  (see  Figs.  354 
to  357). 


FORCEPS 


367 


II'  the  head  is  in  the  lefl  trans- 
verse position,  the  forceps  is  intro- 
duced in  a  similar  manner,  tin'  first 
blade  being  applied  over  I  tie  poste- 
rior ear,  and  the  second  being  rotated 
anteriorly  win il  it  comes  to  lie  oppo- 
site the  first.  In  this  case  one  blade 
lies  in  Front  of  the  sacrum  and  the 
other  behind   the  symphysis. 

In  the  righi  positions,  the  blades 
are  introduced  in  a  similar  manner 
bul  in  opposite  directions,  for  in  this 
ease  the  right  is  the  posterior  ear, 
over  which  the  first  blade  must  be 
applied  (see  Figs.  358  to  360). 

Whatever  the  original  position  of 
the  head  may  be,  delivery  is  effected 
by  making  traction  obliquely  down- 
ward until  the  occiput  appears  at  the 
vulva,  the  rest  of  the  operation  being 
completed  in  the  manner  already  de- 
scribed. When  the  occiput  is  oblique- 
ly anterior  it  gradually  rotates  spon- 
taneously to  the  symphysis  pubis  as 
traction  is  made.  But  when  it  is  di- 
rected transversely,  it  is  sometimes 
necessary  to  impart  a  rotary  motion  to  the  forceps  while  making  traction 
in  order  to  bring  it  to  the  front.    The  direction  in  which  this  is  to  be  made 

varies,  of  course,  according  to 
the  position  of  the  occiput,  rota- 
tion from  the  left  side  towards 
the  middle  line  being  necessary 
when  the  occiput  is  directed 
towards  the  left,  and  in  the  re- 
verse direction  when  it  is  di- 
rected towards  the  right  side  of 
the  pelvis  (see  Figs.  358  to  360). 


-Mid  Forceps,  Introduction  of 
Second  Blade. 


Fig.  356.  Fig.  357. 

Fius.  356,  357. — Mid  Forceps,  Instrument  Applied  in  L.  0.  I.  A. 


368 


OBSTETRICS 


~ 


X 


In  making  traction,  before  the  head  appears  at  the  vulva,  one  or  both 
hands  may  be  employed  according  to  the  amount  of  force  required.  In  the 
latter  case,  when  the  Simpson 
forceps  is  used,  one  hand  grasps 
the  handles  of  the  instrument, 
while  the  fingers  of  the  other 
are  hooked  over  the  transverse 
projection  at  their  upper  ends. 
Care  must  be  taken  not  to  em- 
ploy too  much  force.  To  avoid 
this  error  the  operator  should 
stand  or  sit  with  his  arms  flexed 
and  the  elbows  held  closely 
against  the  thorax,  as  it  is  not 
permissible  to  make  use  of  the 
body  weight,  and  still  less  to 
brace  the  feet  against  the  side 
of  the  bed  (Fig.  361). 


Fig.  358.  Fig.  359. 

Figs.  358,  359.— Mid  Forceps,  Instrument  Applied  in  E.  0.  I.  T. 

Application  of  Forceps  in  Obliquely  Posterior-  Positions. — Prompt  deliv- 
ery frequently  becomes  necessary  when  the  small  fontanelle  is  directed 

towards  one  or  other 
sacro-iliac  synchondro- 
sis— namely,  in  E.  0. 
I.  P.  and  L.  0.  I.  P. 
presentations.  When 
interference  is  required 
in  either  of  these,  the 
head  usually  lies  at  or 
below  the  level  of  the 
ischial  spines,  and  is 
usually  imperfectly 
flexed. 

In  many  cases,  when 
the  hand  is  introduced 
to  locate  the  posterior 
ear,  the  occiput  will  ro- 
tate spontaneously  from 
Fig.  360— Mid  Forceps,  Eotation  to  E.  0.  I.  a   posterior   to    a   trans- 


FORCEPS 


369 


\itm>  position,  and  delivery  by  forceps  is  then  readily  accomplished,  as 
already  described.  If,  however,  rotation  does  not  occur,  the  head  should  be 
seized,  with  four  fingers  over  its  posterior  and  t|ir  Ummb  over  its  anterior 


Fig.  361. — Showing  Manner  of  Making  Traction  in  Mid  Forceps  Operation. 

ear,  and  an  attempt  made  to  rotate  the  occiput  to  a  transverse  position. 
This  can  frequently  be  accomplished  with  great  ease,  and  occasionally  even 


Fig.  362.  Fig.  363. 

Figs.  362,  363. — Diagrams    showing    Rotation   of    Occiput   to    Sacrum   and  Stmphtsis  Pubis 


RESPECTIVELY. 


rotation  to  an  anterior  position  can  be  brought  about.    The  forceps  is  then 
applied  as  described  above. 


370 


OBSTETRICS 


In  a  certain  number  of  cases,  however,  manual  rotation  cannot  be  effect- 
ed, and  the  forceps  must  then  be  applied  with  the  occiput  still  directed  ob- 
liquely posterior.  Under  these  circumstances,  if  the  instrument  be  applied 
to  the  sides  of  the  head,  or  even  obliquely,  and  an  attempt,  made  to  effect 
delivery  by  making  traction  in  the  usual  manner,  great  difficulty  is  ex- 
perienced and  very  powerful  traction  becomes  necessary,  which,  neverthe- 
less, usually  fails  to  bring  about  the  desired  result.  It  is  this  experience 
which  has  given  rise  to  the  great  dread  in  which  these  presentations  are 
generally  held,  and  it  is  a  very  good  practical  rule  whenever  unexpected  dif- 
ficulty is  experienced  in  delivering  what  is  apparently  a  simple  anterior 
presentation,  to  think  of  the  possibility  of  a  mistake  in  diagnosis  and  to 
re-examine  the  patient.  In 
the  vast  majority  of  such  cases 
the  small  fontanelle  will  be 
found  directed  towards  one 
or  other  sacro-iliac  synchon- 
drosis. 

In  order  for  delivery  to 
occur  the  head  must  rotate  so 
as  to  bring  its  sagittal  suture 
into  coincidence  with  the  an- 
tero-posterior  diameter  of  the 
pelvic  outlet.  This  can  be 
accomplished  by  rotating  the 
occiput  by  means  of  the  for- 


Fig.  364.  Fig.  365. 

Figs.  364,  365. — Showing    Inversion    of    Forceps  when  Anterior    Eotation  is  attempted  in 
an  E.  0.  I.  P.  Position,  without  reapplying  the  Instrument. 

ceps,  either  through  an  arc  of  45  degrees  to  the  hollow  of  the  sacrum,  or 
through  one  of  135  degrees  to  the  symphysis  pubis.  The  latter  is  preferable, 
for  the  reason  that  delivery  in  the  former  position  is  more  difficult  and  also 
more  likely  to  give  rise  to  deep  perineal  tears  (Figs.  362  and  363). 

Unfortunately,  when  it  is  desired  to  rotate  the  occiput  forward,  the 
forceps,  if  applied  to  the  sides  of  the  head  in  the  usual  manner,  with  the 
pelvic  curvature  directed  forward,  becomes  inverted  by  the  time  rotation 
is  completed,  so  that  the  pelvic  curve  looks  posteriorly,  and  an  attempted 
delivery  with  the  instrument  in  this  position  is  liable  to  cause  serious 
injury  to  the  maternal  soft  parts  (Figs.  364  and  365).     In  order  to  avoid 


FORCEPS 


371 


tli is.  it  is  best  to  remove  and 
reapply  the  instrument.  If  one 
wishes  to  avoid  i  his  double  appli- 
cation, the  head  may  be  seized 
obliquely  with  one  blade  over 
the  anterior  brow  and  the  other 
over  the  posterior  mastoid  re- 
gion; hut  this  procedure  is  much 
more  difficult  for  the  operator  and 
far  more  dangerous  for  the  child. 

The  double  application  of  for- 
ceps in  this  class  of  cases  was 
recommended    by    Scanzoni    many 


Fig.  366.  Fig.  367. 

Figs.  366,  367. — Scahzohi's  Manoeuvre,  First  Application  of  Fobceps. 

years  ago,  and  in  my  hands  has 
given  such  excellent  results  that 
I  employ  it  to  the  exclusion  of 
all  other  methods.  As  the  right 
occipito-iliac  posterior  occurs 
far  more  frequently  than  the 
left  variety,  I  shall  describe  in 
detail  the  procedure  indicated 
in  the  former. 

In  the  first  step  of  the  opera- 
tion, the  blades  are  applied  to 
the  sides  of  the  head  with  the 
pelvic  curve  looking  towards  the 
face  of  the  child,  whereas  in  the 
second  manipulation  it  looks 
towards  the  occiput.     For  the 


Fig.  368.  Fig:.  369. 

Figs.  368,  369. — Scanzoni's  JIanoxyre,  showing  Rotation  to  Transverse  Position. 
2.5 


372 


OBSTETRICS 


first  application  (Figs.  366  and  367)  the  right  hand  is  passed  into  the 
left  posterior  segment  of  the  genital  tract,  and  the  posterior  (right)  ear 
sought  for.  Over  it  the  left 
"blade  is  applied.  This  is 
held  in  position  by  an  as- 
sistant, while  the  operator's 
left  hand  is  passed  into  the 
right  side  of  the  vagina  and 
over  it  is  introduced  the 
right  blade,  which  is  then 
rotated    anteriorly    until    it 


Fig.  370.  Fig.  371. 

Figs.  370,  371. — Scanzoni's    Manoeuvre,  showing   Kotation  to    Anterior    Position  ;   Forceps 

Inverted. 

comes  to  lie  opposite  the  blade  first  introduced.  The  forceps  is  then  locked, 


its  blades  now  occupying  the 
lique  diameter  of  the  pelvis. 
Downward  traction  is  then 
made  until  the  head  im- 
pinges upon  the  pelvic  floor, 
when  a  rotary  motion  is  im- 
parted to  the  forceps  by 
which  the  occiput  is  slowly 
rotated  to  a  right  transverse, 
and  later  on  to  an  obliquely 
anterior  position  (see  Figs. 
368  and  370). 


left  and  the  sagittal  suture  the  right  ob- 


Fig.  372. 


-^  Fig.  373. 

Figs.  372,  373. — Scanzoni's  Man<euvre,  Second  Application  of  Forceps. 


The  forceps  having  become  inverted  must  be  taken  off,  and  reapplied 
in  the  usual  manner  to  "thVliead7  which'  now  occupies  a  right-amterior 


FORCEPS 


position,  when  delivery  is  readily  accomplished.  Some  difficulty  may  arise 
in  bringing  aboui  proper  articulation,  since  the  handle  of  the  lefi  branch 
lying  above  the  righi  cannoi  be  locked,  hut  this  can  he  readily  overcome 
by  rotating  the  former  around  the  latter  so  as  bo  bring  the  lock  into  proper 
position  (see  Fig.  ;;;  l).  In  Lef1  positions  the  blades  are  applied  in  a  similar 
manner,  hut  in  the  reverse  direction. 

By  this  method  I  have  obtained  most  satisfactory  results,  and  have 
been  able  to  deliver  many  women  with  ease  after  the  usual  methods  had 
failed,  indeed,  my  experience  has  been  so  satisfactory  that  I  have  ceased  to 
dread  occipito-posterior  presentations,  and  now  regard  them  with  equanim- 
ity, feeling  that  delivery 
can  he  readily  and  safely 
effected  when  necessary. 

To  avoid  the  necessi- 
ty of  constantly  bearing 
in  mind  which  is  the  left 
and  which  the  right 
branch  of  the  forceps,  it 
is  a  good  practical  rule 
for  a  beginner,  after  hav- 
ing made  an  accurate  di- 
agnosis of  the  position 
of  the  head,  to  articulate 
the  forceps  and  to  hold 
them  before  the  vulva  of 
the  patient.  In  this  way 
he  readily  appreciates 
how  they  should  be  ap- 
plied, and  which  blade  is 
to  go  over  the  poste- 
rior ear. 

High  Fmrpflfc  —  As 
has  already  been  said. 
the  high  are  much  more 
difficult  than  the  mid  or 
low  forceps  operations, 
and  should  not  be  under- 
taken unless  urgent  indications  are  present.  If  the  head  be  well  engaged, 
the  forceps  should  be  applied  as  in  the  mid  or  low  operation,  except  that. 
owing  to  the  more  elevated  position  of  the  head,  the  blades  must  be  intro- 
duced for  a  greater  distance  into  the  genital  tract. 

On  the  other  hand,  if  the  entire  head  lies  above  the  superior  strait,  or 
only  a  small  segment  of  it  is  engaged,  the  use  of  forceps  should  be  avoided 
if  possible,  as  such  a  condition  usually  indicates  considerable  dispropor- 
tion between  the  head  and  the  pelvis.  If,  however,  the  operation  appears 
to  be  called  for,  the  forceps  should  be  applied  obliquely,  one  blade  over 
the  mastoid  and  the  other  over  the  opposite  brow^  To  my  mind  this  is 
the  omv^Tondition  in  which  the  interests  of  the  mother  and  child  are  not 


Fig.  374. — Scanzoni's   Manoeuvre,  showing  Difficulty  ix 

ARTICULATIXG  BLADES    IX    SeCOXD    APPLICATION    OF  FoP.CF.PS. 


374 


OBSTETRICS 


best  subserved  by  applying  the  forceps  directly  to  the  sides  of  the  head;  but 
under  these  circumstances  there  are  several  contra-indications.  In  the  first 
place,  as  the  pelvis  is  usually  contracted,  the  sagittal  suture  will  generally  lie 
transversely,  and  accordingly  tne  blades  of  the  forceps,  if  applied  to  the 
sides  of  the  head,  will  occupy  the  extremities  of  the  conjugata  vera^nd  thus 
still  further  increase  the  disproportion":  Bui  more  important  still  is  the 
fact  that,  since  the  shape  of  the  birth  canal  makes  it  impossible  for  the 
forceps  to  conform  to  its  axis,  the  posterior  blade  bridges  over  the  anterior 


Fig.  375. — Diagram  showing  Defect  of  Cephalic  Application  of  Forceps  when  Head  is 
at  Superior  Strait  ;  Black  Line  indicating  Direction  of  Actual  and  Dotted  Line 
that  of  Ideal  Traction  (Farabeuf  and  Vamier). 


concavity  of  the  sacrum  and  thus  prevents  the  head  from  entering  the 
pelvic  cavity,  and  so  defeats  the  very  purpose  for  which  the*operation 
would  be  undertaken. 

Axis-traction  Forceps. — With  the  ordinary  long  forceps,  the  high  and 
occasionally  even  the  mid  operation  is  comparatively  difficult,  strong  trac- 
tion being  necessary  to  effect  delivery.  This  is  due  to  the  fact  that,  owing 
to  the  shape  of  the  birth  canal  and  of  the  forceps,  it  is  impossible  to  exert 
traction  directly  in  the  axis  of  the  superior  strait.  The  latter,  as  we  know, 
would,  if  continued  downward,  pass  througli^the  lower  portion  of  the  sa- 
crum; but,  owing  to  the  presence  of  the  peringeum,  the  extremity  of  the 
sacrum  and  the  coccyx,  it  is  impossible  to  depress  the  handles  of  the  forceps 
sufficiently  to  permit  of  traction  in  the  desired  direction.  As  a  consequence, 
a  very  considerable  part  of  the  force  exerted  is  wasted  in  dragging  the 
head  against  the  symphysis  instead  of  bringing  it  downward.  Thus,  Tarnier 
pointed  out  that  a  force  of  40  pounds  employed  in  an  ordinary  high  for- 
ceps operation  would  be  resolved  into  two  forces — one  of  30  pounds  and 


FORCEPS 


<a 


the  other  of  26  pounds — the  former  being  in  the  axis  of  the  superior 
strait  and  serving  to  bring  about  descent,  whereas  the  latter  would  be 
directed  against  the  symphysis  pubis  and  would  not  only  be  wasted  but 
would  actually  retard  delivery. 

F 


Fig.  376. — Tarnier's  Diagram,  shotting  Defects  of  Ordinary  Forceps. 
A  EC,  line  of  actual  traction;  ADB,  line  of  desired  traction;  ASF,  force  wasted  against  sym- 
physis pubis. 

This  defect  in  the  forceps  has  long  been  recognised.  Saxtorph,  in 
1772,  suggested  that  delivery  could  be  greatly  facilitated  by  attaching  a  lac 
to  the  eye  of  each  blade  and  making  traction  upon  these,  as  well  as 


Fig.  377. — Pajot's  Manoeuvre. 

with  the  handles.    He  also  showed  that  a  similar  result  might  be  attained 
by  making  strong  downward  pressure  with  one  hand  in  the  neighbourhood 


376 


OBSTETRICS 


of  the  lock,  while  the  other  was  used  for  traction.  This  manoeuvre  is 
usually  attributed  to  Pajot,  hut  was  recommended  by  Saxtorph  forty-four 
years  before  his  birth. 

Hermann,  of  Berne,  in  1844,  was  the  first  to  attempt  to  overcome 
the  difficulty  by  devising  an  axis-traction  forceps,  his  crude  instru- 
ment being  shown  in  Fig.  378.  Hubert,  of  Louvaine  (1860),  found 
that  in  certain  cases,  by  turning  the  handles  downward,  he  could  make 
traction  along  the  axis  of  the  superior  strait,  his  instrument  giving  ideal 

results  when  the  sagit- 
tal suture  was  directed 
antero-posteriorly,  but 
being  useless  in  all 
other  positions.  Mo- 
rales (1871)  added  a 
perineal  curve  to  the 
forceps,  but  his  in- 
vention possessed  the 
same  disadvantages  as 
that  of  Hubert.  None 
of  these  instruments 
were  of  much  practical 
value,  but  they  served 
to  emphasize  the  faults 
of  those  in  general  use. 
Finally,  in  1877, 
Tarnier  solved  iKe 
problem  by  attaching 
a  traction-rod  to  each 
blade  and  fastening 
them  to  a  handle.  His 
original  forceps  pos- 
sessed a  definite  peri- 
neal curve,  and  was  very  cumbersome.  The  importance  of  his  invention 
was  soon  recognised,  and  obstetricians  throughout  the  world  promptly  at- 
tempted to  improve  upon  it;  so  that  at  present  one  or  more  modifications 
of  axis-traction  for- 
ceps, each  desig- 
nated by  the  name 
of  the  modifier,  are 
to  be  found  in  every 
large  city. 

Tarnier  himself, 
not  considering  his 
original  forceps  sat- 
isfactory, continued 
to  make  changes  and 
improvements,  so  that  before  his  death  he  had  devised  an  instrument  which 
leaves  little  to  be  desired.    It  is  practically  a  long  French  forceps  without 


Fig.  380. — Morales's  Forceps. 


Fig.  381.— Tarniek's  Original  Axis-Traction  Forceps. 


FORCEPS 


377 


Fio.  382.- 


-Tabniee's  Fobceps,  Tbaotion  Bods  in  Place  withoi  i 
Handle-Bab. 


,-i  perineal  curve,  provided   with  short,  detachable  traction-rods,  one  of 
which  is  inserted  just  beyond  the  eye  of  each  blade.    When  not  in  use  these 
are  held  in  place  by 
a  pin  upon  the  un- 
der surface   of   the 
shank,   from   which 
t  hey  can  be  readily 
freed,  and  attached 
by    their   free    ends 
to  a  traction  attach- 
ment which  terminates  in  a  handle-bar  which  can  be  grasped  by  one  or  both 
hands  (see  Figs.  382  and  383). 

With  this  device,  traction  can  be  made  almost  in  the  axis  of  the  superior 
strait,  and,  owing  to  the  presence  or  numerous1  joints  m  the  traction  attach- 
ment, the  instrument  can  be  used  in  any  position.  The  handles  of  the 
forceps  merely  serve  to  indicate  tJie  direction  m  which  traction  should  be 
made,  the  force  being  applied  to  the  handle-bar,  which  is  held  horizontally 
no  matter  what  the  position  of  the  blades  may  be,  the  traction-rods  being 
kept  1  centimetre  beneath  the  handles  (Tig.  384). 

To  my  mind,  this  instrument  is  superior  to  all  other  axis-traction  for- 
ceps, and  with  it  most  excellent  results  can  be  obtained  with  a  minimum 

expenditure  of  energy, 
and  by  its  aid  a  deliv- 
ery can  occasionally  be 
effected  which  would 
have   been  impossible 
with  the  ordinary  in- 
struments.   One  of  its 
best  points  is  the  joint  between  the  horizontal  and  vertical 
portions  of  the  traction  attachment,  as  a  result  of  which  the 
handle-bar  can  be  held  horizontally,  even  though  the  forceps 
is  applied  at  the  ends  of  the  antero-posterior  diameter  of 
the  pelvis.     I  use  this  instrument  in  all  cases,  without  the 
traction-rods  in  low  and  mid,  and  with  them  in  high  forceps 
operations. 

Application  of  Forceps  in  Face  Presentations. — In  face  presentations  the 
application  of  forceps  occasionally  becomes  necessary,  but  should  be  at- 
tempted only  in  the  transvprsp  and  anterior  varieties^  the  blades  being 
applied  to  the  sides  of  the  head  along  the  mento-occipital  diameter,  with 
the  pelvic  curvature  directed  towards  the  neck.  Traction  is  made  in  a  down- 
ward direction  until  the  chin  appears  under  the"  symphysis;  then  by  an  up- 
ward movement  the  face  is  slowly  extracted  through  the  vulva,  the  nose, 
eyes,  brow,  and  occiput  appearing  in  succession  over  the  anterior  margin 
of  the  perinaaum. 

Forceps  should  not  be  applied  when  the  chin  is  directed  towards  the 
hollow  of  the  sacrum,  as  delivery  cannot  be  effected  in  this  position.  In 
rare  instances,  however,  an  expert  operator  may  endeavour  to  rotate 
the  chin  to  a  transverse  and  later  to  an  anterior  position,  though  such 


378 


OBSTETRICS 


attempts  are  rarely  successful,  and  are  permissible  only  in   exceptional 


cases. 


Application  of  Forceps  in  Breech  Presentations. — Occasionally,  the  appli- 
cation of  forceps  is  recommended  in  frank  breech  presentations,  the  blades 
being  applied  over  the  trochanters.  This  is  very  rarely  indicated,  as  de- 
livery can  usually  be  effected  more  satisfactorily  by  the  methods  to  be 
mentioned  in  the  following  chapter. 


.->—.)     <.i- 


Fig.  384. — Diagram  showing  Traction  with  Tarnier's  Forceps. 
A  B  in  proper  and  X  Y  in  improper  manner  (Kibemont-Dessaignes.) 

From  the  time  of  Smellie,  many  authors  have  recommended  the  ex- 
traction of  the  after-coming  head  in  breech  presentations  by  means  of  the 
forceps.  In  such  cases  the  body  of  the  child  is  carried  up  over  the  abdomen 
of  the  mother,  and  the  blades  are  introduced  under  it  and  applied  to  the 
sides  of  the  head.  As  a  matter  of  fact,  it  is  never  necessary  to  resort  to  the 
forceps  under  such  conditions,  so  its  employment  is  not  to  be  recommended, 
since  the  more  expert  one  becomes  in  the  use  of  Mauriceau's  method  of  ex- 
traction the  less  frequently  will  difficult}'-  be  experienced  in  delivering  the 
after-coming  head. 

Prognosis. — Low  and  mid  forceps  operations,  when  intelligently  per- 
formed upon  healthy  women  under  proper  aseptic  precautions,  should  not 
be  followed  by  maternal  mortality,  the  operation  being  undertaken  to  save 
maternal  and  foetal  life. 

It  is  generally  held  that  perineal  tears  occur  more  frequently  in  for- 
ceps than  in  spontaneous  deliveries.     This,  however,  should  not  be  the 


FORCEPS  379 

case,  provided  thai  the  head  is  extracted  sufficiently  slowly.  Unfortunately, 
ii  would  appear  as  though  the  average  operator,  as  soon  as  the  head  ap- 
peal's at  the  vulva,  is  seized  with  an  almost  uncontrollable  desire  to  effecl 
its  immediate  delivery  by  brusque  traction,  instead  of  imitating  nature  and 
devoting  from  fifteen  to  twenty  minutes  to  overcoming  the  resistance  of  the 
perinaeum  and  vulval  outlet.  Leopold  has  stated  that  the  forceps  is  the 
bloodiest  of  all  obstetrical  operations,  and  this  is  undoubtedly  true  if  the 
child  is  rapidly  dragged  through  a  partially  dilated  birth  canal  by  brute 
force.  On  the  other  hand,  if  properly  employed,  it  is  a  means  of  saving 
instead  of  destroying  the  perinaeum,  inasmuch  as  the  exit  of  the  head  can 
be  controlled  more  effectively  by  means  of  the  forceps  than  by  any  other 
procedure. 

Attempts  at  delivery  through  an  imperfectly  dilated  cervix  are  most 
dangerous,  and  frequently  give  rise  to  deep  cervical  tears,  which  may 
lead  to  the  death  of  the  patient  from  haemorrhage  or  infection.  More- 
over, the  application  of  forceps  requires  an  accurate  diagnosis  as  to  the 
position  and  presentation  of  the  child,  and  when  this  is  lacking,  as  in 
certain  occipito-posterior  and  brow  presentations,  and  the  forceps  is  in- 
correctly applied,  delivery  can  be  effected  only  by  brute  force,  which  can 
hardly  fail  to  cause  serious  lesions  for  mother  and  child.  Similar  untoward 
results  often  follow  an  attempt  to  drag  the  head  forcibly  through  a  mark- 
edly contracted  pelvic  brim. 

The  fcetal  mortality  depends  upon  the  position  of  the  head  and  the 
general  difficulty  of  the  operation.  It  should  be  practically  zero  in  low 
and  mid  operations,  except  in  the  rare  cases  in  which  a  funnel-shaped 
pelvis  is  overlooked.  In  a  comparatively  large  experience,  I  can  recall 
only  two  children  whose  deaths  could  be  directly  attributed  to  the  opera- 
tion when  properly  performed.  On  the  other  hand,  the  high  forceps  opera- 
tion is  attended  by  a  very  serious  foetal  mortality,  which  becomes  greater 
the  less  deeply  the  head  is  engaged.  In  such  cases  the  head  may  be  sub- 
jected to  injurious  pressure,  which  may  lead  to  the  rupture  of  intracranial 
vessels  and  the  subsequent  death  of  the  child.  In  rare  instances  actual  frac- 
tiire  of  the  skull  may  occur,  and  occasionally  the  upper  part  of  the  occipitar 
bone  may  become  separated  from  its  base. 

Not  infrequently  the  child  may  be  born  with  facial  paralysis,  or  the 
condition  may  develop  shortly  after  birth.  This  is  most  frequently  noted 
when  the  head  has  been  seized  obliquely,  and  is  due  to  the  pressure  exerted 
by  the  posterior  blade  of  the  forceps  upon  the  neighbourhood  of  the  stylo- 
mastoid foramen,  through  which  the  nerve  leaves  the  skull.  Not  every 
facial  paralysis,  however,  following  delivery  by  forceps,  should  be  attributed 
to  the  operation,  as  such  a  condition  is  occasionally  encountered  after  a 
spontaneous  labour,  and  may  be  due  to  intracranial  causes  quite  independ- 
ent of  the  use  of  instruments.  Full  literature  upon  this  subject  will  be 
found  in  Mace's  article  (1901). 


380  OBSTETRICS 


LITERATURE 


Aveling.     The  Chamberlens  and  the  Midwifery  Forceps.     London,  1882. 
Baudelocque.     De  la  maniere  de  se  servir  du  forceps,  etc.     L'art  des  accouchements. 

Nouv.  ed.,  Paris,  1789,  t.  ii,  300-343. 
Budin.     L'invention  du  forceps  a  double  courbure.     Progres  Medical,  1876,  779. 

Les  Chamberlens.     Lequel  d'entre  eux  iraagina  le  forceps.    Obstetrique  et  Gynecologie, 

1886,  659-668. 
Chapman.     An  Essay  on  the  Improvement  of  Midwifery,  etc.     London,  1733. 
Chassagny.     Le  forceps,  etc.     Paris,  1871. 

Ponctions  du  forceps.     Paris,  1891. 
Farabeuf  et  Varnier.     Introduction  a  Petude  clinique  et  a  la  pratique  des  accouche- 
ments.    Paris,  1891,  276-466. 
Giffard.     Cases  in  Midwifery.     London,  1734. 
Hermann.     Ueber  eine  neue  Geburtszange.     Berne,  1844. 
Hubert.     Note  sur  l'equilibre  du  forceps  et  du  levier.     Memoires  de  l'Acad.  Royale  de 

Belgique,  1860. 
Levret.     Observations  sur  les  causes  et  les  accidents  de  plusieurs  accouchements  labo- 

rieux.    Paris,  1747.  , 

Mace.      Des   paralysies   faciales   spontanees   du   nouveau-ne.      L'Obstetrique,   1901,   vi, 

517-526. 
Morales.     Modification  nouvelle  du  forceps.     Jour,  de  Med.  de  Bruxelles,  1871. 
Mulder.     Historia  literaria  et  critica  forcipum  et  vectium  obstetriciorum,  Lugd.  Bat., 

1794. 
Palfyn.     See  Levret. 

Poullet.     Des  diverses  especes  du  forceps.     Paris,  1883. 
Sanger.     Die  Chamberlens.     Archiv  f.  Gyn.,  1887,  xxxi,  119-144. 
Saxtorph.     Theoria  de  diverso  partu,  etc.     Havniae  and  Lipsiae,  1772. 
Scanzoni.    Lehrbuch  der  Geburtshulfe,  II.  Aufl.,  1853,  838-840. 
Smellie.     A  Treatise  on  the  Theory  and  Practice  of  Midwifery.     London,  1852. 
Tarnier.     Description  de  deux  nouveaux  forceps.     Paris,  1877. 
Witkowski.     L'arsenal  obstetrical.     Paris,  Steinheil. 


CHAPTER   XXI 
EXTRACTION  AND    VERSION 

Extraction  in  Breech  Presentations. — The  delivery  of  the  child  by 
traction  when  the  feet  protrude  from  the  vulva  in  breech  presentations, 
was  probably  the  earliest  obstetrical  operation. 

Prom  the  time  of  Hippocrates  up  to  the  beginning  of  the  sixteenth 
century  head  presentations  alone  were  considered  normal,  and  hence  all  the 
authorities,  with  the  exception  of  Celsus,  advised  the  conversion  of  breech 
into  vertex  presentations  at  any  cost,  even  though  it  rendered  necessary 
amputation  of  the  limbs.  After  the  resuscitation  of  podalic  version  by  Am- 
broise  Pare  and  Jacques  Guillemeau.  more  rational  views  prevailed,  so 
that  in  the  seventeenth  century  we  find  Mauriceau  advising  the  method 
of  extraction  which  is  in  general  use  at  the  present  time. 

As  the  technique  of  the  operation  varies  according  as  one  has  to  deal 
with  a  complete  breech  or  foot,  or  with  a  frank  breech  presentation,  it 
will  be  necessary  to  consider  the  two  conditions  separately.  In  both,  the 
essential  prerequisite  for  the  successful  performance  of  extraction  lies  in 
the  complete  dilatation  of  the  cervix  and  the  absence  of  any  serious  me- 
chanical obstacle.  It  "is  true  that  in  a  certain  number  of  cases  extraction 
through  an  imperfectly  dilated  cervix  is  possible,  but  this  is  usually  effected 
only  at  the  cost  of  deep  cervical  tears.  Moreover,  the  additional  resistance 
offered  to  the  passage  of  the  head  will  generally  lead  to  its  extension,  the 
arms  at  the  same  time  becoming  elevated  over  it,  thereby  so  complicating 
and  delaying  delivery  that  the  child  is  almost  invariably  lost.  For  these 
reasons  premature  extraction  is  indicated  but  rarely,  and  then  only  in  the 
interests  of  the  mother. 

Indications  for  Extraction. — It  has  already  been  pointed  out  that  the 
fcetal  mortality  is  considerably  greater  in  breech  than  in  vertex  presenta- 
tions, since  in  the  former  death  from  asphyxiation  is  almost  inevitable 
if  the  head  be  not  delivered  in  less  than  eight  minutes  after  the  appear- 
ance of  the  umbilicus  at  the  vulva.  In  these  cases  the  untoward  result  may 
be  due  to  one  or  other  of  several  causes.  Thus,  very  often  the  cord  is  sub- 
jected  to  pressure  between  the  pelvic  brim  and  the  head,  which  mav  be 
so  severe  as  fo  completely  check;  the  circulation.  Less  frequently  the  rapid 
decrease  in  the  size  of  the  uterus  following  the  extrusion  of  the  body  of 
the  child  results  in  premature  separation  of  the  placenta  before  the  head 
is  born,  so  that  death  becomes  inevitable  unless  extraction  is  promptly 
effected. 

381 


382 


OBSTETRICS 


In  all  breech  presentations,  preparations  should  be  made  for  extraction 
as  soon  as  the  buttocks  appear  at  the  vulva,  so  that  the  operation  can  be 
promptly  resorted  to  if,  after  the  appearance  of  the  umbilicus,  the  extrusion 
of  the  rest  of  the  body  does  not  rapidly  follow.  In  a  certain  number  of 
cases,  no  matter  what  the  position  of  the  breech,  extraction  may  be  called 
for  by  any  condition  which  seriously  threatens  the  life  of  the  mother  or 
child,  just  as  in  vertex  presentations.  W Tien  speaking  of  tlieTlatter,  how- 
ever, it  was  said  that  the  passage  of  meconium  indicated  that  the  child  was 
in  danger,  whereas  in  breech  presentations  such  an  occurrence  is  without  \ 
significance,  as  it  is  simply  the  result  of  the  compression  to  which  the  abdo-  / 
men  of  the  child  is  being  subjected. 

Extraction  by  One  or  Both  Feet. — Before  beginning  the  operation  the 
patient  should  be  brought  to  the  edge  of  the  bed  and  subjected  to  the  usual 
preliminary  preparations.  Complete  anaesthesia_  is  necessary,  except  in 
those  cases  in  which  the  body  of  tlie^child  has  already  been  born  and  only 
the  head  remains  to  be  extracted. 

As  a  rule,  extraction  is  an  extremely  simple  operation  when  the  breech 
has  been  born  spontaneously,  whereas  it  is  less  so  when  the  feet  are  in 

the  vagina,  and  very 
much  more  difficult 
when  the}'  are  still 
within  the  uterus.  In 
the  latter  case,  one 
hand  should  be  passed 
through  the  cervix  and 
an  attempt  made  to 
seize  both  feet,  the 
ankles  being  grasped 
in  such  a  manner  that 
the  second  finger  lies 
between  them.  They 
are  then  brought  down 
into  the  vagina,  and 
traction  is  made  un- 
til they  appear  at  the 
vulva.  If,  however, 
difficulty  is  experi- 
enced in  seizing  both 
feet,  one  should  be 
grasped  and  extracted 
in  a  similar  manner. 

As  soon  as  the  feet 
emerge  from  the  vulva 
they  should  be  wrapped 
in  a  sterile  towel  so  that  a  firmer  grasp  may  be  obtained;  since  the  vernix 
caseosa  renders  them  so  slippery  that  they  are  very  difficult  to  hold.  Trac- 
tion is  then  made  in  a  downward  direction,  and  as  the  legs  protrude  still 
farther  they  are  grasped  higher  up,  first  by  the  calves  and  later  by  the 


Fig.  385. — Breech  Extraction,  Teactiox  rPO>~  Feet. 


EXTRACTION   AND   VERSION 


■ 


thighs.    When  the  breech  appeal-.  ai  the  vulva,  traction  is  made  in  an  up- 

The  thumbs  are  then  applied  over  the 


ward  direction  until  it  is  delivered 
sacrum  and  the  fin- 
gers over  the  hips,  and 
traction  is  continued 
in  the  same  manner 
until  the  thorax  is 
born,  when  the  arms 
must  be  freed  in  order 
to  effed  delivery. 

If  only  one  foot 
has  been  seized,  trac- 
tion should  be  made 
upon  -it  until  the  but- 
tocks appear  at  the 
vulva,  when  the  index 
finger  of  the  other 
h  a  n  d  is  introduced 
into  the  posterior 
groin  and  aids  in 
traction. 

As  soon  as  the 
operator  begins  to  pull 
upon  the  legs,  an  as- 
sistant or  the  nurse 
should  exert  strong 
pressure  upon  the  ute- 


Bkeech  Extraction,  Tractiox  dpok  Thighs. 


rus  in  the  axis  of  the 

superior  strait,  with  the  object  of  preserving  the  flexed  attitude  of  the 

head  and  preventing  the  arms  from  becoming  extended  above  it.    Besides 

serving  these  purposes  it  also  aids  directly  in  the  expulsion  of  the  child,  and 

thus  renders  necessary   a   smaller  amount  of  force   on  the   part   of  the 

operator. 

In  order  to  free  and  deliver  the  arms,  the  child  should  be  seized  with 
the  thumbs  over  the  scapula3  and  the  fingers  over  the  sides  of  the  thorax, 
and  rotated  until  the  bisacromial  diameter  occupies  an  oblique  diameter  of 
the  pelvis  (Fig.  387).  The  posterior  arm  should  be  freed  first,  since  there  is 
more  available  space  in  the  posterior  and  lateral  segments  of  the  pelvis  than 
elsewhere.  To  accomplish  this,  the  feet  should  be  seized  by  one  hand  and 
carried  towards  the  groin  of  the  mother  opposite  the  posterior  shoul- 
der. In  many  cases  this  manoeuvre  causes  the  latter  to  emerge  over  the 
perineal  margin,  the  hand  and  arm  escaping  spontaneously.  If  this  does 
not  occur  two  fingers  are  introduced  beneath  the  shoulder  and  passed  along 
the  humerus  until  the  elbow  is  reached  (Fig.  388).  The  fingers  are  now 
applied  in  such  a  way  as  to  serve  as  a  splint  to  the  arm.  which  is  swept  down- 
ward over  the  thorax  and  delivered  from  the  vulva.  To  effect  the  delivery 
of  the  anterior  arm.  the  body  is  seized  as  before  and  rotated  so  as  to  bring 
the  undelivered  shoulder  into  the  neighbourhood  of  the  nearest  sacro-sciatic 


384 


OBSTETRICS 


notch.  The  legs  are  then  carried  upward,  so  as  to  "bring  the  body  to  the 
opposite  groin  of  the  mother,  and  if  the  arm  be  not  born  spontaneously 
it  is  delivered  in  the  same  manner  as  the  other. 

If  pressure  from  above  has  not  been  made — and  occasionally  in  spite 
of  it — the  arms  may  become  extended  over  the  head.    Under  such  circum- 
stances   their   delivery,   al- 
1      though  more  difficult,  can 
be     accomplished    by    the 

— _ • manoeuvres   ordinarily   em- 

■—— """",  ployed.    In  doing  this,  par- 

ticular care  must  be  taken 
to  carry  the  fingers  up  to 
the  elbow  and  use  them  as 
a  splint,  for  if  the  finger  be 
merely  hooked  over  the  arm 
and  strong  traction  made, 
the  humerus  or  clavicle  is 
exposed  to  great  danger  of 
fracture.  Occasionally,  the 
manoeuvre  may  be  rendered 
easier  by  pushing  the  child 
a  short  distance  up  the  gen- 
erative tract. 

In  other  cases  the  arm 
is  found  around  the  back 
of  the  neck,  when  its  de- 
livery becomes  still  more 
difficult.  If  it  cannot  be 
freed  in  the  manner  just 
described,  it  must  be  forci- 
bly extracted  by  hooking  a 
finger  over  it.  Unfortu- 
nately, fracture  of  the  hu- 
merus is  very  common  in  such  cases,  and  the  dangers  attending  the  pro- 
cedure should  be  pointed  out  to  some  responsible  member  of  the  family; 
although,  inasmuch  as  the  life  of  the  child  can  be  saved  only  in  this  way, 
the  risk  is  always  justifiable. 

After  the  shoulders  have  been  born,  the  head  usually  occupies  an  oblique 
diameter  of  the  pelvis  with  the  chin  directed  posteriorly,  when  its  extraction 
is  best  effected  by  Mauriceau's  manoeuvre  (Figs.  389  and  390).  For  this  pur- 
pose the  index  finger  of  one  hand  is  introduced  into  the  mouth  of  the  child 
and  applied  over  the  superior  maxilla,  while  the  body  rests  upon  the  palm  of 
the  hand  and  the  forearm,  with  the  legs  straddling  the  latter.  Two  fingers 
of  the  other  hand  are  then  hooked  over  the  neck,  and,  grasping  the  shoul- 
ders, make  downward  traction  until  the  occiput  appears  under  the  sym- 
physis. The  body  of  the  child  is  now  raised  up  towards  the  mother's  ab- 
domen, and  the  mouth,  nose,  brow,  and  eventually  the  occiput,  successively 
emerge  over  the  perinseum.    Traction  should  be  exerted  only  by  the  fingers 


Fig.  387.- 


-Breech  Extraction,  Posterior  Rotation  of 
Shoulder. 


EXTRACTION    AND    VERSION 


385 


over  the  shoulders,  and  not  by  the  finger  in  the  mouth,  since  in  many 
cases  the  latter  slips  from  the  superior  maxilla  and  comes  to  rest  upon  the 
inferior  maxilla  and  base  of  the  tongue,  as  a  consequence  of  which  serious 
injuries  may  be  done  t<>  the  child  if  energetic  traction  be  employed. 

This  manoeuvre  was  first  practised  by  Mauriceau  in  the  seventeenth  cen- 
tury, but  for  some  reason  fell  into  disfavour.  Nearly  a  hundred  year-  later 
Smellie  described  a  similar  procedure,  but  rarely  made  use  of  it,  as  he  pre- 
ferred the  employment  of  forceps.  In  the  meantime  other  devices  came 
into  use.  until  (i.  Veit,  in  1863,  directed  attention  to  the  inestimable  ad- 
vantages  which  Mauriceau's  method  of  extraction  possessed  overall  others. 
For  this  reason  in  Germany  the  procedure  is  frequently  called  after  Veit, 
or,  when  greater  accuracy  is  desired,  is  designated  as  the  Mauriceau-Smellie- 
Veit  manoeuvre.    Litzmann,  however,  is  certainly  right  in  pointing  out  the 


Fig. 


-Breech  Extraction,  Introduction  of  Fingers  to  Free  Posterior  Arm. 


impropriety  of  such  a  nomenclature,  and  insisting  that  only  the  name  of 
the  original  inventor  (Mauriceau)  should  be  used  in  describing  it.  Numer- 
ous other  methods  of  extraction  have  been  devised.  Winckel  being  able  in 
1888  to  collect  21  different  procedures  from  the  literature,  although  none 
has  proved  as  serviceable  as  that  of  Mauriceau. 

In  the  vast  majority  of  cases  the  back  of  the  child  eventually  rotates 
towards  the  front,  no  matter  what  its  original  position;  but  when  it  does 
not  take  place  spontaneously  the  movement  may  be  inaugurated  bv  making 
stronger  traction  upon  the  leg,  which  would  naturallv  rotate  anteriorlv. 


— " — — — ^        '^Jfe» 


\  6 


^ 


Fig.  389. — Breech  Extraction,  Mauriceau's  Manoeuvre, 
Downward  Traction. 


\      \ 


Fig.  390. — Breech  Extraction,  Mauriceau's  Manceuvre,  Upward  Traction. 


EXTRACTION    AND    VERSION 


:;s- 


It*  this  docs  not  bring  aboul  the  desired  result,  and  the  back  remains  pos- 
terior after  the  birth  of  the  shoulders,  extraction  must  be  begun  with  the 
occiput  posterior.  As  a  rule,  rotation  can  still  he  effected  by  means  of 
the  finger  in  the  month,  after  which  the  head  can  be  extracted  by  Mauri- 
ceau's  manoeuvre.  When,  however,  this  is  impossible,  delivery  must  be 
attempted,  with  the  head  in  its  abnormal  position,  by  the  employment  of  a 
modified  Prague  manoeuvre,  which  is  so  called  for  the  reason  that  its  ad- 
vantages weTe  SltuugU  m^TTl  and  practised  more  particularly  by  Kiwisch, 
of  that  city,  although  it  had  been  described  by  Pugh  a  century  earlier. 
The  procedure  is  somewhat  as  follows:  Two  fingers  of  one  hand  grasp  the 
shoulders,  while  the  other  hand  draws  up  the  feet  over  the  abdomen  of 


Fig.  391. — Delivery  of  After-Coming  Heap,  Back  Posterior  (Bumm\ 


the  mother.  As  a  result  the  occiput  of  the  child  is  born  first  and  the 
perinseum  is  necessarily  subjected  to  greater  liability  of  rupture. 

Prognosis. — The  prognosis,  so  far  as  the  mother  is  concerned,  is  very 
favourable,  even  when  considerable  disproportion  exists  between  the  child 
and  the  pelvis,  since  the  pressure  to  which  the  maternal  soft  parts  are  sub- 
jected lasts  but  a  few  seconds,  instead  of  being  prolonged  for  hours,  as 
in  head  presentations.  Owing  to  the  necessary  intra-vaginal  manipula- 
tions, there  is  a  slightly  increased  danger  of  infection.  _and  more  particu- 
larly in  the  case  of  a  primipara  with  a  rigid  vaginal  outlet  there  is 
greater  liability  to  laceration  of  the  peringeum  than  in  head  presentations. 

For  the  child,  however,  the  outlook  is  not  so  favourable,  and  becomes 
more  serious  the  higher  the  situation  of  the  presenting  part  at  the  begin- 
ning of  the  operation.  The  foetal  mortality  is  in  great  part  due  to  the 
26 


388  OBSTETRICS 

dangers  inherent  to  breech  presentations,  which  are  augmented  by  the 
greater  liability  to  the  occurrence  of  traumatism  during  extraction,  particu- 
larly if  there  is  marked  disproportion  between  the  head  and  the  pelvis. 

As  has  already  been  said,  fractures  of  the  humerus  and  clavicle  cannot 
always  be  avoided,  even  in  the  hands  of  expert  operators.  Occasionally 
hcematomata  of  the  sterno-cleido-mastoid  muscle  are  noted  after  the  opera- 
tion,  though  these  are  usually  of  but  slight  significance  and  disappear  spon- 
taneously within  a  short  time.  More  serious  results,  however,  may  follow 
the  separation,  of  the  epiphyses  of  the  scapula  or  humerus.  In  exceptional 
cases  paralysis  nf  tkp,  arm  results  from  pressure  exerted  upon  the  brachial 
plexus  by  the  fingers  in  making  traction,  but  more  frequently  is  due  to  an 
overstretching  of  the  neck  in  freeing  the  arms  or  in  effecting  extraction 
by  the  Prague  manoeuvre.  As  will  be  shown  in  Chapter  XLV,  the  condi- 
tion usually  undergoes  spontaneous  cure,  although  in  rare  instances  it  per- 
sists throughout  life. 

When  the  child  is  forcibly  extracted  through  a  markedly  contracted 
pelvis,  spoon-shaped  depressions  or  actual  fractures  of  the  skull  may  result, 
which  generally  prove  fatal. 


Fig.  392. — Extraction  of  Frank  Bbeech,  Finger  in  Anterior  Groin. 


The  application  of  forceps  to  the  after-coming  head,  introduced  by  Smellie, 
has  been  extensively  practised.  Under  such  circumstances  the  body  of  the 
child  is  elevated  towards  the  abdomen  of  the  mother  and  the  forceps  in- 


EXTRACTION    AND    VERSION 


389 


troduced  under  it,  the  blades  being  applied  to  the  sides  of  the  head.  Per- 
sonally. 1  have  never  Found  it  necessary  to  resort  to  this  procedure,  and 
believe  that  it  is  bu1  rarely  called  for  if  the  obstetrician  has  made  himself 
thoroughly  familiar  with  Mauriceau's  manoeuvre. 

Extraction  of  Frank  Breech  Presentations. — When  indications  for  de- 
livery arise  after  the  breech  has  descended  into  the  birth  canal,  its  extrac- 
tion can  usually  be  effected  with-  out  difficulty  by  hooking 
the  index  finger  of  one  hand  into  the  anterior  groin  and 
making  traction  until  the  buttocks  appear  at  the  vulva,  the 
index  finger  of  the  other  hand  being  then  inserted  into 
the   posterior  groin    in   order   to                  ^       furnish  additional   aid. 


Fig.  393. — Extraction  of  Frank  Breech.  Fingers  in  Groins. 


On  the  other  hand,  when  the  breech  is  at  the  superior  strait  delivery- 
is  much  more  difficult.  In  such  cases  it  is  advisable  to  try  to  decompose 
the  wedge  and  bring  down  one  or  both  feet,  which  can  be  readily  accom- 
plished if  attempted  shortly  after  rupture  of  the  membranes,  but  be- 
comes extremely  difficult  if  a  considerable  time  has  been  allowed  to  elapse 
after  the  escape  of  the  liquor  amnii  and  the  uterus  has  become  tightly  con- 
tracted over  the  child. 

In  many  cases  the  employment  of  the  following  manoeuvre  suggested 
by  Pinard  will  often  aid  materially  in  bringing  down  the  foot:  Two  fingers 
are  carried  up  along  one  leg  to  the  knee  and  push  it  away  from  the 
middle  line.  This  procedure  is  usually  followed  by  spontaneous  flexion, 
and  the  foot  of  the  child  will  be  felt  to  impinge  upon  the  back  of  the  hand, 
when  it  can  be  readily  seized  (Fig.  394). 

In  view  of  the  fact  that  it  is  often  very  difficult  to  seize  and  bring 


390 


OBSTETRICS 


down  a  foot  in  the  latter  part  of  the  second  stage  of  labour,  Ahlfeld  and 
others  have  suggested  the  propriety  of  rupturing  the  membranes  as  soon 
as  the  cervix  is  fully  dilated,  and  bringing  down  a  foot  prophylactically,  so 
that  a  convenient  Handle  may  be  available  in  case  extraction  becomes  neces- 
sary. This  can  be  readily  accomplished,  but 
\  is  not  advisable  as  a  routine  practice,  since 

the  frank  breech  forms  a  much  better  dilat- 
ing wedge  than  the  incomplete  breech-  pres- 
entation. The  procedure  is  justifiable,  how- 
ever, in  those  cases  in  which  it  is 
highly  probable  that  rapid  delivery 
will  become  imperative;  for  instance, 
in  patients  suffering  from  acute  dis^ 
eases  and  heart  lesions. 


\, 


A . 


[f  the  indication  for  delivery  is 
urgent,  and  it  is  impossible  to  bring 
down  a  foot,  the  child  must 
be  extracted  as  it  lies.     For 
this  purpose  the  index  finger 
of  one  hand  is  hooked  intoi 
the  anterior  groin,  and  strong/ 
downward  traction  made,) 
supplemented,   if   neces- 
sary, by  the  use  of  the 
other  hand  which  grasps 
the  wrist.     This  proced- 
ure   is    continued    until 
the  posterior  buttock  has 
almost  reached  the  pel- 


Fig.  394. — Pinard's  Manceuvre  for  bringing  Down  a  Foot 
in  Frank  Breech  Presentation. 

vie  floor,  when  the  index  I 
finger  of  the  other  hand  is  hooked  into  the  posterior  groin  and  traction ' 
made  with  both  hands.  As  soon  as  the  latter  becomes  accessible,  delivery 
can  usually  be  readily  effected,  but,  unfortunately,  in  a  considerable  num- 
ber of  cases  one  is  unable  to  bring  the  breech  low  enough  to  offer  this 
advantage.  For  this  reason,  when  the  breech  is  high  up,  its  extraction 
should  not  be  attempted  unless  imperatively  demanded  by  the  condition 
of  the  mother  or  child;  otherwise  it  is  far  better  to  wait  until  it  has  de- 
scended lower  before  interfering. 

As  soon  as  the  buttocks  are  born,  first  one  leg  and  then  the  other  is\ 
drawn  out  and  extraction  accomplished  as  described  above.     As  was  said/ 
before,  traction  must  always  be  supplemented  by  pressure  upon  the  abdo-J 
men  from  above.     This  precautionary  measure  should  never  be  neglected, 
as  delivery  can  frequently  be  accomplished  by  its  aid  when  it  would  be 
impossible  if  traction  by  the  fingers  were  alone  relied  upon.     Indeed,  it  is 
not  until  one  has  attempted  a  difficult  frank  breech  extraction  that  one 
learns  how  little  force  can  be  exerted  by  the  fingers. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  less  favour- 
able,  in  frank  breech  than  in  foot  presentations.     In  the  former  the  in- 


EXTRACTION    AND    VERSION  391 

creased  manipulation  affords  greater  opporj nniiy  for  infection;  while  the 
attempt  to  reach  the  posterior  groin  often  gives  rise  to  deep  tears  before 
the  child  has  reached  the  perinaeum.  Again,  in  new  of  the  longer  time 
required  to  effeci  delivery,  the  cliilil  is  exposed  to  more  danger,  and  in 
addition  to  the  accidents  incident  to  extraction  by  the  feet,  fracture  of 
the  femur  may  follow  the  attempt  to  bring  down  a  foot,  especially  when 
strong  traction  is  made  upon  the  groin. 

Use  of  Forceps. — In  view  of  the  difficulty  which  sometimes  attends  the 
extraction  of  the  frank  breech  when  high  up,  Lusk,  Budin,  Reynolds,  and 
other  authorities  have  recommended  the  employment  of  forceps,  the  blades 
being  applied  obliquely,  one  over  the  sacrum  and  the  other  over  the  thigh. 
dp  to  the  present  time  I  have  had  no  experience  with  this  procedure,  having 
been  able  to  effect  delivery  in  all  my  cases  by  traction  exerted  with  a 
linger  in  the  groin.  When  this  fails  the  application  of  forceps  is  certainly 
justifiable,  although  when  the  breech  is  high  up  it  should  not  be  attempted 
except  under  pressing  indications. 

The  Fillet. — In  these  cases  it  is  sometimes  convenient  to  make  use  of 
the  fillet.  This  may  consist  of  several  thicknesses  of  sterile  gauze  bandage 
which  are  passed  over  the  anterior  groin.  The  fillet  is  a  very  efficient 
tractor,  but  its  application  offers  considerable  difficulty.  Unless  the  oper- 
ator has  at  his  disposal  a  specially  constructed  instrument,  a  fairly  satis- 
factory carrier  may  be  improvised  from  a  rubber  catheter,  through  which 
a  piece  of  stout  thread  is  passed,  a  loop  being  allowed  to  protrude  from 
the  eye.  A  stylet  is  then  introduced,  and  an  appropriate  curve  having 
been  given  to  the  closed  end  of  the  catheter,  the  bent  extremity  is  passed 
around  the  anterior  groin  until  the  fingers  in  the  vagina  can  seize  the  loop, 
to  which  one  end  of  the  fillet  is  attached  and  then  cautiously  drawn  up 
into  place. 

Aside  from  the  difficulty  encountered  in  applying  it.  the  only  disad- 
vantage of  the  fillet  is  its  liability  to  cut  through  the  skin  of  the  groin; 
but  this  accident  can  be  avoided  by  employing  several  thicknesses  of 
gauze  and  taking  care  that  they  do  not  become  twisted  into  a  cord. 

The  older  authors  advocated  making  traction  upon  the  groin  by  means 
of  a  metallic  hook.  This  instrument  should  never  be  employed  upon 
living  children  on  account  of  its  liability  to  cause  fracture  of  the  femur. 
On  the  other  hand,  when  the  child  is  dead  and  such  an  accident  is  a 
matter  of  indifference,  the  hook  affords  a  most  convenient  means  of 
making  traction. 

Version. — Version,  or  turning,  is  an  operation  through  which  the  pres- 
entation of  the  foetus  is  artificially  altered,  one  pole  being  substituted  for 
the  other,  or  an  oblique  or  transverse  being  converted  into  a  longitudinal 
presentation. 

According  as  the  head  or  breech  is  made  the  presenting  part,  the  opera- 
tion is  spoken  of  as  cephalic  or  podalic  version  respectively.  It  is  also 
designated  according  to  the  method  by  which  it  is  accomplished.  Thus 
we  speak  of  external  version  when  the  manipulations  are  made  exclusively 
through  the  external  abdominal  wall:  of  internal  version  when  the  entire 
hand  is  introduced  into  the  uterine  cavity;  and  of  combined  version  when 


392  OBSTETRICS 

one  hand  manipulates  through  the  abdominal  wall  while  two  or  more  fingers 
of  the  other  are  introduced  through  the  cervix. 

Cephalic  Version. — This  operation  was  practised  from  the  most  remote 
antiquity,  and  only  gradually  fell  into  disfavour  after  the  introduction  of 
podalic  version  by  Pare  and  his  followers.  After  the  discovery  of  Wigand 
(1807)  that  the  position  of  the  child  could  easily  be  altered  by  external 
manipulations,  cephalic  version  came  into  more  general  use,  and  since  the 
publications  of  Hubert  and  Pinard  has  become  a  well-recognised  procedure 
in  certain  conditions. 

The  object  of  the  operation  is  to  substitute  a  vertex  for  a  less  favour- 
able presentation.  As  it  does  not,  however,  afford  a  means  for  immediate 
delivery,  its  field  of  usefulness  is  comparatively  limited,  and  its  employ- 
ment is  still  further  restricted  by  various  contra-indications. 

Indications. — If  a  breech  or  transverse  -presentation  is  diagnosed  in  the 
last  few  weeks-  of  pregnancy,  its  conversion  into  a  vertex  should  be  at- 
tempted by  external  manoeuvres,  provided  there  be  no  marked  'dispro- 
portion between  the  size  of  the  child  and  the  pelvis.  If  the  breech  be  not 
engaged,  cephalic  version  is  indicated  by  reason  of  the  increased  foetal 
mortality  attending  spontaneous  delivery  in  that  presentation;  while 
if  the  child  lies  transversely  a  change  of  presentation  is  imperatively 
demanded,  inasmuch  as  a  natural  labour  is  out  of  the  question,  and  if  ) 
appropriate  measures  are  not  adopted  the  lives  of  both  mother  and  child  J 
will  be  lost. 

Unfortunately,  after  the  accomplishment  of  external  cephalic  version, 
the  child  tends  to  return  to  its  original  position,  unless  the  new  presentation 
can  be  retained  until  engagement  occurs.  Consequently,  whenever  this  pro- 
cedure is  employed  during  pregnancy,  the  wearing  of  a  suitable  bandage  is 
necessary.  Moreover,  the  operation  can  be  accomplished  only  under  the 
following  conditions:  (1)  The  presenting  part  must  not  be  engaged:  (2) 
the  abdominal  wall  must  be  sufficiently  thin  to  admit  of  accurate  palpa- 
tion; (3)  the  abdominal  and  uterine  walls  must  not  be  too  irritable;  (4)  the 
uterus  must  contain  a  sufficient  quantity  of  liquor  amnii  to  permit  the 
easy  movement  of  the  child.  Given  these  essentials,  external  cephalic  ver- 
sion should  always  be  attempted,  since  it  is  absolutely  harmless,  and  if  the 
new  position  is  maintained  it  may  do  away  with  the  necessity  for  serious 
operative  procedures  at  the  time  of  labour. 

In  the  early  stages  of  labour,  before  the  membranes  have  ruptured,  the 
same  indications  hold  good,  and  at  this  time  may  be  extended  to  oblique 
presentations  as  well,  though  these  usually  right  themselves  spontaneously  as 
labour  progresses.    On  the  other  hand,  external  cephalic  version  is  not  indi-j 
cated  after  the  cervix  has  become  fully  dilated  and  the  membranes  have  rup-7 
tared,  except  in  occasional  cases  of  shoulder  presentations;  since  it  can  be 
effected  but  rarely,  and  better  results  are  obtained  from  podalic  version 
followed  by  immediate  extraction.    This  is  particularly  true  in  cases  com-  . 
plicated  by  prolanse_of  the  cord  or  placenta  pravia.     Serious  pelvic  con_-  J 
traction  is  a  decided  contra-indication,  since  although  it  may  be  readily 
accomplished,  the  procedure  is  useless,"  and  more  serious  operative  measures 
will  be  necessary  before  delivery  can  be  effected. 


EXTRACTION    AND    VERSION 


Methods. — Cephalic  version  may  be  brought  about  either  by  external 
manipulations  alone,  or  by  the  combined  method — with  one  hand  on  the 
abdomen  and  two  or  more  fingers,  or  even  the  whole  hand,  in  the  uterus. 
During  pregnancy  the  former  is  the  only  method  applicable,  and  at  the 
time  of  labour  it  should  be  employed  whenever  feasible.     The  techniquep     • 
has  been  carefully  described  by  PinarcL and  is  somewhat  as  follows:  The'  ^ 
patient'-  abdomen  having  been  bared,  the  presentation  and  position  of  the 
child  are  carefully  mapped  out.    The  fcetal  poles  are  then  seized  with  either 
hand  and  the  one  which  we  wish  to  present  is  gently  stroked  towards  the 
superior  strait,  while  the 
other  is  moved  in  the  op- 
posite   direction.     After 
version   has    been    com- 
pleted, the  child  must  be 
held  in  its  new  position 
until  engagement  occurs. 
During  pregnancy  this  is 
accomplished  by   appro- 
priately   fitting    pads, 
which  are  held  in  place 
by  a  bandage;  but  at  the 
time  of  labour  the  head 
may    be    pressed    down 
into   the   superior   strait 
and  held  firmly  in  posi- 
tion   until    it    becomes 
fixed  under  the  influence 
of  the   uterine   contrac- 
tions. 

At  the  time  of  labour, 
if    external    manipula- 
tions prove  futile,  ceph-  ^a. 
alic  version  may  be  accomplished  by  the  combined  method  of  Braxton  Hicls 
as  soon  as  the  cervix  is  sufficiently  dilated  to  admit  of  two  fingers.     For      ■ — 
carrying  out  this  procedure  Hicks  gave  the  following  directions: 

"  Introduce  the  left  hand  into  the  vagina  as  in  podalic  version.  Place 
the  right  hand  on  the  outside  of  the  abdomen  in  order  to  make  out 
the  position  of  the  foetus  and  the  direction  of  the  head  and  feet.  Should 
the  shoulder,  for  instance,  present,  then  push  it  with  one  or  two  fingers 
on  the  top  in  the  direction  of  the  feet.  At  the  same  time  pressure  by  the 
other  hand  should  be  exerted  upon  the  cephalic  end  of  the  child.  This 
will  bring  the  child  close  to  the  os.  Then  let  the  head  be  received  upon  the 
tips  of  the  inside  fingers.  The  head  will  then  play  like  a  ball  between  the 
hands,  and  can  be  placed  at  almost  any  part  at  will.  ...  It  is  well,  if  the 
breech  will  not  rise  to  the  fundus  readily  and  the  head  is  fairly  in  the  os, 
to  withdraw  the  hand  from  the  vagina  and  with  it  press  up  the  breech  from 
the  exterior." 

Busch,  D'Outrepont,  and  others  advocated  attempting  cephalic  version 


Fig.  395. — External  Cephalic  Version  (Pinard). 


394 


OBSTETRICS 


after  complete  dilatation  of  the  cervix,  by  introducing  one  hand  into 
the  uterus  and  seizing  the  head,  while  the  other  is  employed  for  external 
manipulations.  This  is  rarely  if  ever  advisable,  as  under  such  circum- 
stances it  is  preferable  to  perform  internal  version,  which  is  no  more  dan- 
gerous, and  at  the  same  time  permits  immediate  delivery  if  necessary. 

Podalic  Version. — By  this  is  understood  the  seizure  of  one  or  both  feet 
by  two  or  more  fingers,  and  drawing  them  through  the  cervix,  the  operation 
being  usually  followed  by  extraction.  Podalic  version  was  introduced  and 
warmly  advocated  by  P_are,  and,  until  the  invention  of  the  forceps,  afforded 
the  only  means  of  artificially  delivering  unmutilated  children.  It  is  inter- 
esting to  note  that  G-uillemeau,  one  of  Pare's  students,  was  enabled  by  this 
means  to  save  his  master's  daughter  from  dying  of  hemorrhage  due  to 
placenta  prsevia.  The  value  of  the  operation  was  recognised  and  insisted 
upon  by  Louise  Bourgeois,  Mauriceau,  and  among  many  others  by  De  la 
Motte,  who  employed  it  very  frequently  with  most  excellent  results. 

Indications. — Podalic  version  is  indicated  in  two  great  groups  of  oajres 
— namely,  in  transverse  and  oblique  presentations  and  in  head  presentations 

in  which  it  is  believed  that  delivery  canV 
be  more  safely  and  more  rapidly  accom-l 
plished  after  version. 

The  necessity  for  version  in  trans- 
verse and  oblique  presentations  is  obvi- 
ous. In  abnormal  head  presentations, 
when  the  face,  brow,  or  occiput  is  poste- 
rior and  movable  above  the  superior 
strait,  delivery  can  frequently  be  more 
readily  accomplished  after  version  than 
by  any  other  means.  Podalic  version  is  I 
usually  the  operation  of  choice  in  pro-_ 
lapse  of  the  extremities  or  irrnhilinal  norrh 
and  in  many  cases  of  placenta  prsevia. 
Moreover,  when  the  child  presents  some 
deformity  delivery  is  sometimes  very 
much  facilitated  after  version.  Gener- 
ally speaking,  the  operation  is  indicated 
in  all  cases  requiring  prompt  delivery 
when  the  head  is  floating  at  the  superior  I 
strait  or  is  but  slightly  engaged,  provided 
there  is  no  great  disproportion  between 
its  size  and  that  of  the  pelvis.  Under 
such  circumstances  it  is  usually  a  much 
safer  procedure  than  the  application  of 
high  forceps. 

One  of  its  widest  fields  of  usefulness  is  after  the  manual  dilatation  of  the 
pervix  in  accouchement  force,  especially  in  eclamnsia  and  hsemorxh&g^;  when 
version  and  extraction  supply  the  readiest  and  most  conservative  method 
of  delivery. 

Marked  degrees  of  pelvic  deformity  contra-indicate  the  operation.     It 


Fig 


396. — Seizure  of-  Foot  in  Internal 
Podalic  Version  (Tarnier). 


EXTRACTION    AND    VERSION 


395 


is  true  that  version  can  be  accomplished,  but  afterward  it  is  frequently 
impossible  to  extract  an  iinmutilated  child.  It  should  never  be  attempted 
when  the  child  is  suffering  from  ItjidmceghQh&s* 

The  most  favourable  lime  for  the  performance  of  the  operation  is 
immediately  after  the  rupture  of  the  mj_-iiil",:l1"1*,  before  the  amniotic  fluid 
has  drained  off,  and  while  the  child  is  readily  movable  in  any  direction. 
Generally  speaking,  podalic  version  should  not  be  attempted  through  an  im- 
perfectly dilated  cervix,  except  in  certain  cases  of  placenta  praavia. 


Fig.  397. — Version  :  Transverse  Presenta- 
tion, Back  Anterior,  Seizure  of  Lower 
Foot. 


Fig.  398. — Version:  Transverse  Presenta- 
tion, Back  Anterior,  Seizure  of  Upper 
Foot. 


In  many  cases  the  patient  is  not  seen  until  long  after  rupture  of  the 
membranes,  and  conditions  may  be  present  which  render  the  operation 
extremely  difficult  or  even  impossible.  For  example,  the  uterus  may  he 
tetanic-ally  contracted  and  so  tightly  applied  to  the  body  of  the  child 
as  to  render  even  the  introduction  of  the  hand  extremely  difficult.  In 
other  cases,  if  a  long  interval  has  elapsed  since  the  rupture  of  the  mem- 
branes, the  contraction  ring  may  have  risen  to  such  an  extent,  and  the 
lower  uterine  segment  be  so  stretched  as  to  render  the  operation  dangerous  » 
in  the  highest  degree,  as  the  attempt  at  version  will  probably  lead  to  rup-J 
ture  of  the  uterus. 

Technique^— -The  patient  should  he  anaesthetized  and  placed  upon   a 
table  or  brought  to  the  edge  of  the  bed,  and  the  usual  preparations  for  an 


396 


OBSTETRICS 


operation  made.  Version  should  never  be  undertaken  without  an  accurate 
diagnosis  as  to  the  presentation  and  position  of  the  child.  The  abdomen 
should  be  covered  by  sterile  towels  so  as  to  allow  one  hand  to  be  applied 
over  its  lower  portion  without  becoming  infected. 


Fig.  399.— Version:  Transverse  Presenta- 
tion, Back  Posteeioe,  Seizcee  of  Uppee 
Foot. 


Fig.  400. — Veesion  :  Teansveese  Peesentation, 
Back  Posteeioe,  Seizuee  of  Lower  Foot, 
showing  Aeeest  of  Buttocks  at  the  Pel- 
vic Brim. 


Podalic  version  may  be  accomplished  by  one  or  two  methods — internal 
or  combined.  In  the  former  the  entire  hand  is  introduced  into  the  uterus, 
while  in  the  latter  only  two  fingers  are  pressed  through  the  cervix;  but  in 
both  methods  the  other  hand  is  applied  over  the  abdomen  and  controls  the 
movements  of  the  foetus. 

Internal  Podalic  Version. — This  should  be  attempted  only  after  com- 
plete dilatation  of  the  cervix.  If  the  membranes  are  intact,  tliey  are  rup- 
tured and  the  hand  is  immediately  introduced  into  the  uterus;  the  feef 
are  then  seized  and  drawn  through  the  cervix,  the  operation  being  usually, 
but  not  necessarily,  followed  by  extraction.  The  method  of  procedure  varies 
somewhat,  according  as  one  has  to  do  primarily  with  a  head  or  a  transverse 
presentation.  In  the  first  instance  the  hand  and  arm  must  be  introduced 
considerably  farther  into  the  genital  canal  than  in  the  latter  (Fig.  396). 

If  the  child  presents  by  the  head,  the  choice  of  the  hand  which  is  to  be 
passed  into  the  uterus  depends  upon  the  location  of  the  small* parts.     If 


EXTRACTION   AND   VERSION 


597 


3 

i 


the  back  be  directed  to  the  left,  the  fed  can  lie  seized  most  conveniently 
with  the  left  hand,  ami  virr  rcrsn.  (ienerally  speaking,  it  is  advisable  to 
aitempl  to  grasp  only  one  foot — if  possible  the  anterior  one — for  when  trac 
tionismade  upon  it  the  back  will  rotate  to  the  front.  The  feet  may  be  d if 
ferentiated  by  tracing  the  course  of  the  thigh  and  leg  or  by  noting  the 
relation  <>!'  the  great  inc.  Saving  found  the  proper  foot,  the  ankle  should 
be  grasped  between  the  index  and  second  fingers,  and  slowly  drawn  through 
the  cervix,  while  the  external  hand  controls  and  guides  the  movements  of 
the  head. 

In  transverse  presentations  one  foot  is  seized  and  version  accomplished 
in  the  same  manner.  The  choice  of  the  foot,  however,  is  a  matter  of  very 
considerable  importance.  When  the  back  is  directed  anteriorly,  the  lower 
one  should  be  seized,  as  by  so  doing  the  back  of  the  child  is  kept  directed 
towards  the  symphysis;  whereas,  if  the  upper  foot  be  seized  the  back  may 
turn  in  the  opposite  direction.  On  the  other  hand,  when  the  back  looks  pos- 
teriorly, the  upper  is_th"  fnot  of  r-hoir-p.  since  traction  upon  it  will  cause  the 
back  to  rotate  to  the  front;  while,  if 
the  lower  foot  be  seized,  although 
anterior  rotation  will  usually  occur, 
the  upper  buttock  is  liable  to  im- 
pinge upon  the  anterior  portion  of 
the  pelvic  brim,  and  great  force 
may  become  necessary  to  effect  its 
disiodgment  (Figs.  397  to  400). 

Xot  a  few  cases  of  transverse 
presentation  are  complicated  by 
the  prolapse  of  an  arm  into  the 
vagina.  Under  such  circumstances, 
a  fillet  should  be  applied  around 
the  wrist  and  held  loosely  by  an 
assistant,  while  version  is  per- 
formed in  the  usual  manner.  In 
this  way  the  arm  is  prevented  from 
becoming  extended  over  the  head, 
and  the  necessity  of  freeing  it  dur- 
ing extraction  is  obviated. 

"Whatever  may  have  been  the 
original  position  of  the  child,  firm 
pressure  should  be  exerted  upon 
the  fundus  of  the  uterus  as  soon  as 
extraction  is  begun,  in  order  to 
facilitate  the  delivery  and  at  the 
same  time  prevent  extension  of  the 
head  or  arms. 

Combined  Podalic  Version. — In    Fig.  401—  Bipolar  Podaijc  Veesion  iBumm). 
other  instances,  particularly  in  pla- 
centa prsevia,  version  may  be  attempted  by  the  combined  or  bipolar  method 
as  soon  as  the  cervix  is  sufficiently  dilated  to  admit  two  fingers.     TVith 


398  OBSTETRICS 

these  the  presenting  part  is  dislodged  and  pushed  upward,  while  the  external 
hand  gradually  brings  the  breech  downward  towards  the  external  os.  As 
soon  as  a  foot  can  be  felt  it  is  seized  by  the  two  fingers  and  drawn  through 
the  cervix.  For  the  time  being  this  finishes  the  operation,  as  extraction 
should  not  be  thought  of  until  the  cervix  is  fully  dilated,  for  it  is  extremely 
difficult  and  can  be  effected  only  at  the  cost  of  deep  cervical  tears. 

Prognosis. — For  the  mother,  the  prognosis  following  podalic  version  is 
excellent  in  properly  selected  cases,  provided  the  patient  be  in  good  con- 
dition at  the  commencement  of  the  operation.  On  the  other  hand,  when 
attempted  in  the  case  of  a  tetanically  contracted  uterus,  or  when  the  lower 
uterine  segment  is  overstretched,  forcible  attempts  at  version  may  lead  to 
the  rupture  of  the  organ  and  death. 

The  prognosis  for  the  child  is  fairly  good,  and  depends  upon  the  nature 
of  the  indication  and  the  difficulty  experienced  in  extraction.  On  the  other 
hand,  if  the  operation  be  undertaken  through  an  imperfectly  dilated  cer- 
vix,  and  the  child's  head  be  arrested  by  the  external  os,  the  time  required 
for  its  extraction  is  usually  so  great  that  death  from  asphyxiation  is  in- 
evitable. Moreover,  in  cases  of  marked  pelvic  contraction,  the  fcetal  mor- 
tality is  very  high.  In  many  such  cases  forcible  traction  may  enable  one  to 
deliver  the  child,  but  usually  not  until  after  the  cord  has  been  so  long  com- 
pressed as  to  have  caused  pronounced  asphyxia  and  death,  not  to  mention 
injuries  to  the  head  resulting  from  pressure. 


LITERATURE 

Ahlfeld.     Ueber  Behandlung  gedoppelten  Steisslagen,  etc.     Arehiv  f.  Gyn.,  1873,  v, 

174-1 76. 
Bourgeois.  Louise.     Observations  diverses,  etc.     Paris.  1609. 
Budix.     Tarnier  et  Budin,  Traite  de  l'art  des  aecouchements.  1901,  t.  iv,  296. 
De  la  Motte.     Traite  complet  des  aecouchements.     Xouv.  ed.,  Leiden,  1729. 
D'Outrepoxt.     Abh.  und  Beitrage,  Wiirzburg,  1817,  Theil  I.  69. 
Guillemeau.     De  l'heureux  accouchement  des  femmes.     Paris.  1609. 
Hicks.     On  combined  External  and  Internal  Version.     London,  1864. 
Hubert.     Quelques  faits  sur  les  presentations  vieieuses  du  foetus  et  sur  la  possibility  de 

les  corriger  par  les  manipulations  exterieures.     Annales  de  Gyn.  et  de  Ped.,  1843, 

aoiit. 
Kiwisch.     Beitrage  zur  Geburtskunde.  Wiirzburg,  1846.  I.  Abth..  69. 
Litzmaxx.     Der  Maurieeau-Levret'sehe  Handgriff.     Arehiv  f.  Gyn..  1887,  xxxi,  102-118. 
Lusk.     The  Science  and  Art  of  Midwifery.     Xew  York.  1895,  338-391. 
Mauriceau.     Le  moyen  d'accoucher   la  femme,  quand   Tenfant    presente   un  ou  deux 

pieds  les  premiers.     Traite  des  maladies  des  femmes  grosses.     6me  ed.,  1721,  280-285. 
Pare.    Edition  Malgaigne,  1840,  t.  ii.  623. 
Pixard.     De  la  version  par  les  manoeuvres  externes.     Traite  du  palper  abdominal,  Paris, 

1889. 
Quoted  by  Farabeuf  and  Varnier,  Introduction  a  l'etude  clinique  des  aecouchements. 

Paris,  1891,  185-187. 
Pugh.      A   Treatise   on   Midwifery   chiefly   with   Regard   to   the   Operation.      London 

1754. 
Reynolds.     The  Value  of  Forceps  in  Complicated  High  Arrest  of  the  Breech.     Amer. 

Jour.  Obst.,  1892,  xxvi,  586. 


EXTRACTION    AND    VERSION  399 

Smki.uk.    The  Firsl  Class  of  Preternatural  Labours,  when  the  Feet,  Breech,  or  Lower 

Parts  of  the  Foetus  Present.     A.  Treatise  on  the  Theory  and  Practice  of  Midwifery, 

eighth  edition,  L774,  195-206. 
Veit,  Gh     Oeber  die  beste  Methode  zur  Extraction  des  nachfolgenden  Kindeskopfes. 

G-reifswalder  med.  BeitrSge,  1863,  ii,  Eefl  I. 
Wigand.     Ceber  Wendung  durch  aussere  Handgriffe.     Hamburger  med.  Mag.,   ls(>7, 

i,  52. 
Winckel.    Zur  BefOrderung  der  Geburt  d(.'.s  nachfolgenden  Kopfes.     Verh.  d.  deutschen 

Gesellsch.  f.  Gvn.,  1888,  ii,  19-32. 


CHAPTEE  XXII 
CESAREAN  SECTION  AND  SYMPHYSEOTOMY 

Csesarean  Section. — In  this  operation  the  child  is  removed  from  the 
uterns  through  an  incision  in  the  abdominal  and  uterine  'walls.  The  origin 
of  the  term  has  given  rise  to'  a  great  deal  of  discussion.  It  has  been  gener- 
ally asserted  that  Julius  Cassar  was  brought  into  the  world  by  this  means, 
and  obtained  his  name  from  the  manner  in  which  he  was  delivered  (a  cceso 
matris  utero).  This  explanation,  however,  can  hardly  be  correct,  as  his 
mother,  Julia,  lived  many  years  after  her  son's  birth;  and,  besides,  Julius 
was  not  the  first  of  his  name,  since  there  is  mention  of  a  priest  named  Cassar 
who  lived  several  generations  before.  The  following  view,  however,  would 
at  least  appear  to  be  more  plausible.  In  the  Eoman  law,  as  codified  by 
Xuma  Pompilius,  it  was  ordered  that  the  operation  should  be  performed 
upon  women  dying  in  the  last  few  weeks  of  pregnancy.  This  lex  regia, 
as  it  was  called  at  first,  under  the  emperors  became  converted  into  the  lex 
cwsarea,  and  the  procedure  itself  became  known  as  the  C cesarean,  operation. 

History. — The  history  of  Cesarean  section  may  be  said  to  extend  over 
three  periods,  the  first  lasting  from  the  earliest  times  to  the  beginning  of 
the  sixteenth  century.  During  this  period  the  operation  -was  occasionally 
resorted  to  after  the  death  of  the  mother,  in  the  hope  of  saving  the  child, 
but  it  is  improbable  that  it  was  practised  upon  the  living  woman,  although 
several  authorities  are  inclined  to  believe  that  certain  passages  in  the  Tal- 
mud may  be  so  interpreted.  The  fact  that  Dr.  Felkin  saw  -a  Cesarean 
section  performed  among  the  natives  of  Uganda  renders  it  possible  that  it 
may  have  been  employed  upon  the  living  woman  at  an  early  period  by  cer- 
tain of  the  uncivilized  races. 

The  second  period  extends  from  the  year  1500  to  1876,  when  Porro 
described  his  method  of  amputating  the  pregnant  uterus. 

According  to  Caspar  Bauhin,  the  first  Cesarean  section  upon  a  living 
woman  was  performed  in  1500.  when  Jacob  Xufer,  a  castrator  of  pigs  at 
Sigerhausen,  Switzerland,  operated  .successfully  upon  his  own  wife  after 
she  had  been  given  up  by  the  midwives  and  barbers  in  attendance.  The 
fact,  however,  that  the  woman  had  five  spontaneous  labours  later  would 
go  to  show  that  this  was  not  a  true  Csesarean  section,  but  probably  the  sim- 
ple removal  of  an  extra-uterine  child  from  the  abdominal  cavit};:  . 

Frangois  Eousset,  a  contemporary  of  Pare,  wrote  a  treatise  upon  the 
subject  in  1581,  in  which  he  gave  the  histories  of  a  number  of  Cesarean 
400 


(  j:sai:i:a.\   SECTION  AND  SYMPHYSEOTOMY  4"1 

sections  collected  from  various  sources:  Several  of  them  \\<'V<>  probably 
apocryphal,  while  others,  in  all  probability,  were  operations  for  advanced 
extra-uterine  pregnancy.  Eis  article,  however,  had  the  merit  of  directing 
attention  to  the  operation  and  to  the  possibility  of  performing  ii  upou 
the  living  woman.  The  iir>t  authentic  Cesarean  section  was  probably 
done  in  L610  by  Trautmann,  of  Wittenberg.  Following  this,  it  was  occa- 
sionally performed  upon  the  Irving  woman  up  to  1777,  when  it  became 
temporarily  eclipsed  by  symphyseotomy,  to  he  taken  up  again  after  the 
latter  operation  fell  into  disrepute. 

During  this  period  the  uterus  was  simply  incised  and  the  child  ex- 
tracted.  The  uterine  walls  were  not  sutured,  the  contraction  and  retrac- 
tion of  the  organ  being  relied  upon  to  cheek  hemorrhage.  Most  of  the 
women  perished  from  haemorrhage  or  infection.  Sutures  were  first  em- 
ployed  by  Lebas  (1769),  but  did  not  come  into  general  use  until  after  the 
appearance  of  Sanger's  epoch-making  article  upon  the  subject  in  1882. 

Before  the  work  of  Porro  and  Sanger,  the  mortality  following  the  opera- 
tion was  appalling.  Meyer  (1867)  collected  1,605  eases  from  the  litera- 
ture with  a  mortality  of  54  per  cent:  while  in  80  cases  performed  in  the 
United  States  up  to  1878.  collected  by  Harris,  52.5  per  cent  of  the  women 
died.  According  to  Budin,  not  a  single  successful  Cesarean  section  was 
performed  in  Paris  between  the  years  1787  and  1876.  Such  poor  results 
were  obtained  by  physicians  that  Harris  pointed  out  that  the  operation  was 
more  successful  when  performed  by  the  patient  herself,  or  when  the  abdo- 
men was  ripped  open  by  the  horn  of  an  infuriated  bull.  He  collected  9 
such  cases  from  the  literature  with  5  recoveries,  and  stated  that  out  of  11 
Cesarean  sections  performed  in  the  city  of  Xew  York  during  the  same 
period,  onlv  one  patient  recovered. 

The  third  period  began  with  the  year  1876,  when  Porro  advised  ampu- 
tating the  body  of  the  uterus  and  stitching  the  cervical  stump  into  the 
lower  angle  of  the  abdominal  wound  in  order  to  lessen  the  danger  from 
hemorrhage  and  infection.  This  procedure  being  followed  by  very  satis- 
factory results,  soon  became  quite  popular,  so  that  in  1890  Harris  was 
able  to  collect  264  operations  from  the  literature.  Storer,  of  Boston,  in 
1868,  performed  a  similar  operation  upon  a  pregnant  myomatous  uterus, 
with  a  fatal  result,  but  inasmuch  as  he  did  not  appear  to  recognise  the  im- 
portance of  the  innovation,  the  credit  for  proposing  it  undoubtedly  be- 
longs to  Porro. 

Sanger,  in  1882.  revolutionized  the  Cesarean  section  by  directing  atten- 
tion to  the  necessity  for  the  employment  of  uterine  sutures.  As  the  uterus 
was  not  sacrificed  in  this  operation,  it  was  designated  as  the  conservative, 
in  contradistinction  to  the  Porro  Cesarean  section.  "With  the  increasing 
perfection  of  surgical  technique  more  and  more  satisfactory  results  were 
obtained  from  the  former  operation,  while  the  latter  became  less  popular. 

After  the  supravaginal  amputation  of -the  myomatous  uterus  had  become 
more  perfected,  similar  methods  were  applied  to  the  Porro  operation,  the 
cervical  stump  being  covered  by  a  flap  of  peritoneum  and  dropped  into  the 
abdominal  cavity:  while  in  a  small  number  of  cases,  particularly  when  the 
cervix  was  carcinomatous,  the  entire  organ  was  removed. .  The  latter  pro- 


402  OBSTETRICS 

cedure,  which  was  first  attempted  by  Bisehoff,  has  a  limited  field  of  appli- 
cation. 

Indications. — The  most  frequent  and  important  indication  for  Csesarean 
section  is  afforded  by  pelves  which  are  so  contracted  as  to  offer  a  serious 
mechanical  obstacle  to  labour.  The  pelvic  indication  may  be  either  absolute 
or  relative,  the  upper  limits  being  a  conjugata  vera  of  5  and  7.5  centimetres 
respectively.  In  the  former  the  contraction  is  so  pronounced  that  the 
birth  of  the  child  cannot  be  effected  by  any  other  means;  while  in  the 
latter  it  is  sufficiently  marked  to  render  spontaneous  labour  impossible,  but 
permits  delivery  after  craniotomy.  When  the  conjugata  vera  measures  not 
^less  than  6.5  centimetres,  a  living,  not  overlarge  child  may  be  delivered 
after  symphyseotomy. 

In  view  of  the  excellent  results  which  now  follow  Cesarean  section, 
and  the  fact  that  the  spontaneous  delivery  of  an  ordinary  full-term  child 
is  out  of  the  question  when  the  conjugata  vera  is  less  than  7  centimetres,] 
the  upper  limit  for  the  absolute  indication  has  been  extended  to  that  point,] 
provided  the  patient  is  in  good  condition  and  amid  suitable  surroundings 
for  a  major  operation.    Other-wise  the  old  limits  are  retained. 

At  the  1901  meeting  of  the  American  G-ynseeological  Society,  I  advo- 
cated that  the  relative  indication  be  likewise  broadened  in  appropriate 
cases,  and  its  upper  limit  placed  at  a  conjugata  vera  of  8.5  centimetres  in 
flat,  and  9  centimetres  in  generally  contracted  pelves. 

In  cases  of  this  character,  the  r-mn^P  n-f  labour  will  depend  upon  the 
size  and  consistency  of  the  head  and  the  character  of  the  uterine  contrac- 
tions.  Given  two  women  with  pelves  of  the  same  size,  one  may  have  a 
spontaneous  and  easy  labour,  while  the  other  may  require  Cesarean  sec- 
tion for  delivery.  In  such  cases  the  operation  is  undertaken  primarily  in 
the  interests  of  the  child,  instead  of  resorting  to  high  forceps,  version,  or 
craniotomy.  The  patient  is  allowed  to  go  into  labour,  to  complete  the  first 
and  enter  the  second  stage.  In  most  cases  the  head  becomes  engaged,  and 
spontaneous  delivery  occurs.  On  the  other  hand,  if  signs  of  engagement 
are  wanting  after  one  hour  of  strong  second-stage  pains,  the  propriety  of 
performing  Cesarean  section  should  be  considered,  provided  the  patient  has 
not  been  subjected  to  repeated  vaginal  examinations,  is  in  good  condition, 
and  in  the  hands  of  a  competent  operator.  By  so  doing  nearly  all  the 
children  will  be  saved,  and  quite  as  many  mothers  as  after  difficult  high- 
forceps  operations  or  craniotomy.  If,  however,  these  conditions  cannot  be 
fulfilled,  Cesarean  section  becomes  a  very  dangerous  procedure  and  should 
not  be  considered.  In  such  cases  the  patient  should  be  allowed  to  continue 
in  labour  until  a  definite  indication  for  its  termination  arises,  when  high 
forceps,  version,  or  craniotomy  should  be  resorted  to  according  to  the 
exigencies  of  the  particular  case. 

There  is  a  general  misconception  as  to  the  innocuousness  of  craniotomy, 
a  somewhat  general  belief  existing  that  it  is  unattended  by  maternal  mor- 
tality. The  results  of  Pinard  and  Bar,  however,  prove  the  contrary,  as  their 
mortality  was  11.5  and  9.39  per  cent  respectively.  At  the  same  time,  it 
must  be  admitted  that  many  of  their  patients  were  infected  and  in  bad 
condition  when  first  seen,  and  consequently  their  results  were  infinitely 


CESAREAN    SECTION  AND  SYMPHYSEOTOMY  403 

worse  than  they  would  have  been  had  all  been  clean  eases.  But  when  this 
t'nri  has  received  full  consideration,  their  figures  si  ill  serve  to  show  that  the 
operation  is  not  devoid  of  danger  even  when  undertaken  under  favourable 
conditions. 

Pelvic  contraction  involving  the  superior  strait  is  not  the  only  indica- 
tion for  Csesarean  section;  in  not  a  few  cases  abnormalities  of  the  pelvic 
outlet  likewise  call  for  its  performance.  Under  such  circumstances  a  bis- 
ischial  diameter  oj  1  centimetres  or  less  is  a  positive  indication  for  the 
operation.  Other  pelvic  deformities  which  occasionally  necessitate  the 
operation  will  be  considered  in  the  chapter  upon  Contracted  Pelves. 

Obstruction  to  labour,  due  to  conditions  other  than  pelvic  contraction, 
occasionally  affords  an  indication  for  the  operation.  Thus,  myomata  in  the 
lower  segment  of  the  uterus,  as  well  as  ovarian  and  other  tumours  which 
are  prolapsed  and  cannot  be  replaced  under  anaesthesia,  may  so  block  the 
pelvic  canal  as  to  render  Cesarean  section  imperative.  The  same  may  be 
said  of  certain  cicatricial  contractions  of  the  cervix  or  vagina. 

Carcinoma  of  the  cervix  occasionally  results  in  the  formation  of  such 
dense  and  rigid  tissue  that  dilatation  becomes  impossible.  In  such  cases 
Csesarean  section  is  demanded  in  the  interests  of  both  the  child  and  mother, 
and  should  be  supplemented  by  total  hysterectomy,  if  the  disease  be  not 
too  far  advanced.'  In  rare  instances  malignant  tumours  of  the  rectum  may 
so  obstruct  the  pelvic  canal  as  to  render  Csesarean  section  imperative.  Holz- 
apfel  lately  reported  a  case  of  this  character  and  collected  6  others  from 
the  literature. 

Halbertsma  suggested  Csesarean  section  as  the  best  method  of  deliv- 
ery- in  certain  cases  of  eclampsia  complicated  by  an  mutilated  and  rigid 
cervix.  Olshausen's  experience  also  favours  this  view.  In  exceptional 
cases,  m  a  well-regulated  hospital,  it  is  certainly  a  more  conservative  pro- 
cedure than  the  forcible  dilatation  of  a  cartilaginous  and  rigid  cervix. 

Contra-indications. — Uvccpt  in  the  presence  of  an  absolute  indication, 
Cesarean  section  should  never  be  performed  when  the  child  is  dead  or  in 
serious  uanger.  it  is  likewise  contra-indicated  when  the  mother  is  in- 
fected, in  poor  condition,  or  among  surroundings  which  render  an  aseptic  i 
operation  impracticable.  Under  such  circumstances  craniotomy  is  the 
operation  of  choice,  and  Cesarean  section  should  not  be  undertaken  unless 
a  living  child  is  earnestly  desired;  and  then  only  after  the  risks  incident  to 
it  have  been  clearly  explained  to  a  responsible  member  of  the  family.  Again, 
the  operation  is  usually  contra-indicated  when  the  patient  has  been  subject- 
ed to  repeated  vaginal  examinations  during  labour  by  one  whose  technique 
is  questionable,  even  though  no  signs  of  infection  are  apparent  at  the  time. 
If,  however,  the  operation  should  be  decided  upon  in  the  presence  of  such 
risks,  the  entire  uterus  should  be  removed  after  delivery  of  the  child. 

Operative  Technique:  (a)  Conservative  C cesarean  Section. — When  under- 
taken for  the  absolute  or  even  for  the  relative  indication,  if  previous 
labours  have  repeatedly  ended  in  the  birth  of  dead  children,  the  operation, 
if  possible,  should  be  performed  at  an  appointed  time,  a  day  or  so  prior  to 
the  expected  onset  of  labour.  In  many  cases,  however,  especially  in  hos- 
pital practice,  this  is  out  of  the  question,  inasmuch  as  the  patient  is  often 


401  OBSTETRICS 

not  seen  until  she  is  well  advanced  in  labour.  Moreover,  in  the  border 
line  eases,  with  the  broadened  relative  indication,  the  patient  must  be  al- 
lowed to  go  into  labour  in  order  to  afford  Xature  an  opportunity  of  demon- 
strating what  she  can  do.  In  such  cases  only  one  vaginal  examination 
should  be  made,  and  that  not  until  some  time  has  elapsed  after  the  rupture 
of  the  membranes.  Then,  if  there  appears  to  be  no  likelihood  of  spon- 
taneous delivery,  Cesarean  section  should  be  promptly  performed,  as  the 
prospects  for  recovery  decrease  in  almost  geometrical  ratio  for  every  hour 
elapsing  after  the  onset  of  the  second  stage. 

When  the  operation  can  be  performed  at  a  fixed  time,  the  patient  should 
be  prepared  exactly  as  for  an  ordinary  abdominal  operation.  On  the  night 
before,  after  she  has  received  a  full  bath,  the  abdomen  should  be  shaved, 
disinfected,  and  covered  with  a  bichloride  compress.  The  bowels  should 
be  evacuated  by  an  appropriate  cathartic,  and  an  enema  given  a  few  hours 
before  she  is  put  upon  the  table. 

Just  before  the  beginning  of  the  operation,  the  bladder  is  catheterized 
and  the  abdomen  redisinfected  in  the  usual  manner  with  permanganate  of 
potassium,  oxalic  acid,  bichloride  of  mercury,  alcohol,  and  ether.  The 
woman  is  then  placed  in  the  dorsal  or  a  slightly  elevated  Trendelenburg 
position,  and  the  entire  body,  except  the  field  of  operation,  is  covered  with 
sterile  towels.  If  the  patient  is  not  seen  until  labour  has  set  in,  similar 
preparations  should  be  made,  except  that  the  bath  and  the  administration 
of  a  cathartic  must,  of  course,  be  dispensed  with. 

In  addition  to  the  operator,  four  assistants  are  needed,  one  to  give  the 
anaesthetic,  one  to  assist  directly  at  the  wound,  and  two  to  handle  the  in- 
struments, ligatures,  and  sponges.  With  the  exception  of  the  anaesthetist, 
all  should  wear  rubber  gloves  throughout  the  operation.  A  competent 
person  should  be  charged  with  the  reception  and  care  of  the  child  and 
receive  careful  instructions  as  to  the  best  method  of  resuscitating  it  if 
necessary.  The  following  instruments  are  required:  1  scalpel,  1  long 
blunt  -pointed  scissors,  2  dissecting  forceps,  12  short  and  6  long  artery 
clamps,  an  abdominal  retractor,  a  needle-holder  and  appropriate  needles, 
as  well  as  the  usual  sterile  dressings,  suture  materials,  and  gauze  sponges. 

An  incision  from  16  to  18  centimetres  long  should  be  made  in  the  linea 
alba  with  the  umbilicus  as  its  middle  point.  In  this  way  injury  to  the 
bladder,  which  often  extends  one"  third  or~even  one  half  of  the  distance 
between  the  symphysis  and  umbilicus,  and  also  to  the  lower  uterine  seg- 
ment, is  avoided.  The  abdominal  walls  are  usually  verv  thm  and  bleed 
but  little,  rarely  "more  than  two  or  three  clamps  being  required  to  check 
haemorrhage. 

The  uterus  will  be  found  immediately  beneath  the  incision.  As  soon 
as  it  is  exposed,  sterile  gauze  handkerchiefs  should  be  tucked  between  it 
and  the  margins  of  the  abdominal  incision.  If  it  lies  obliquely,  its  long  axis 
should  be  brought  into  coincidence  with  that  of  the  wound,  and  the  organ 
opened  in  situ,  provided  the  patient  is  not  infected.  The  escape  of  amni- 
otic fluid  into  the  peritoneal  cavity  can  be  prevented  by  having  the  assist- 
ant press  the  edges  of  the  abdominal  wound  firmly  against  the  uterus.  If, 
however,  there  is  any  question  as  to  the  sterility  of  its  contents,  the  uterus 


CESAREAN   SECTION   AND  SYMPHYSEOTOMY  4<)5 

should  be  delivered  through  the  abdominal  incision  and  not  cut  into  until 
it  has  been  carefully  packed  oil",  so  that  all  possibility  of  contaminating 
the  abdominal  cavity  may  be  avoided. 

The  anterior  surface  of  the  uterus  is  opened  longitudinally  along 
middle  line.  This  is  best  accomplished  by  making  an  incision  a  few  cen- 
timetres long  with  a  scalpel,  and  then  rapidly  enlarging  M  with  the  scis- 
sors to  10  or  IS  centimetres.  The  membranes  are  then  ruptured,  the 
child  is  seized  by  one  foot  and  rapidly  extracted.  Two  clamps  are  applied 
t.i  the  cord]  which  is  cut  Between  them]  and  the  child  handed  to  an 
assistant.  This  takes  but  a  short  time,  and  it  is  rare  for  more  than  ninety 
seconds  to  elapse  between  the  beginning  of  the  operation  and  the  birth  of 
the  child.  Many  authorities  recommend  that  an  attempt  be  made  to  locate 
the  position  of  the  placenta  beforehand,  so  that  the  incision  may  be  made  in 
such  a  way  as  to  avoid  it.  This,  however,  is  not  necessary.  If  the  placenta 
lies  under  the  incision  it  should  be  rapidly  cut  through  or  pushed  to  one 
side  and  the  child  extracted.  This  is  accompanied  by  a  slight  increase  of 
haemorrhage,  but  as  the  operation  is  necessarily  bloody,  and  as  the  bleed- 
ing is  only  momentary,  it  is  without  significance.  Immediately  after  the 
delivery  of  the  child  the  uterus  contracts  down  and  haemorrhage  practically 
ceases.  The  contracted  organ  should  then  be  delivered  from  the  abdomen, 
and  the  edges  of  the  abdominal  incision  above  it  brought  together  by  an 
artery  clamp  and  covered  by  a  sterile  towel,  so  as  to  prevent  the  uterus 
coming  in  contact  with  the  skin  surface.  If  the  placenta  and  membranes 
have  not  become  separated  spontaneously  they  should  be  peeled  off  and 
removed  with  the  hand,  care  being  taken  that  no  shreds  of  membranes  are 
left  behind.    Disinfection  of  the  uterine  cavity  is  not  necessary. 

To  prevent  haemorrhage,  Litzmann  recommended  that  an  elastic  liga.=-, 
ture  be  applied  about  the  cervix  before  opening  the  uterus.  This  is,  how- 
ever, an  unnecessary  precaution;  nor  is  it  devoid  of  danger,  as  the  prolonged 
compression  predisposes  to  uterine  atony  and  haemorrhage  afterward.  If, 
however,  there  is  considerable  loss  of  blood  after  the  delivery  of  the  child, 
the  assistant  should  grasp  the  cervix  firmly  between  his  fingers  and  com- 
press the  uterine  arteries.  This  effectually  controls  haemorrhage  and  is 
preferable  to  the  employment  of  a  rubber  ligature,  as  transient  compression 
only  is  needed,  and  the  fingers  can  be  removed  as  soon  as  the  object  is 
accomplished. 

Fritsch,  in  1897,  proposed  opening  into  the  uterus  through  a  imns- 
lyrse  incision  over  the  fundus,  instead  of  by  the  usual  method,  holding 
that,  the  course  of  blood-vessels  in  that  location  being  parallel  to  the  in- 
cision, the  haemorrhage  would  therefore  be  less.  His  proposal  was  at  once 
tested  by  many  operators.  Trinks,  Hiibl,  Halm,  and  H.  Schroeder  have 
published  tables  of  cases  so  operated  upon,  the  latter  having  collected  94 
cases.  The  results  were  excellent,  but  not  better  than  those  following  the 
more  usual  incision. 

There  would  appear  to  be  no  especial  advantage  in  adopting  Fritsch's 
suggestion,  except  in  the  small  number  of  cases  in  which  it  is  desired  to 
sterilize  the  patient  by  excising  the  tubes.  On  the  other  hand,  there  are 
several  objections  to  its  employment.    In  the  first  place,  it  requires  a  longer 


406  OBSTETRICS 

abdominal  incision  and  the  evisceration  of  the  uterus.  _  Moreover,  the  intes- 
tines and  omentum  are  more  liable  to  become  adherent  to  the  uterine  wound 
wTEh  the  transverse  than  with  the  longitudinal  incision.  It  is  urged  that  the 
fundal  wound  is  less  likely  to  be  followed  by  adhesions  between  the  uterus 
and  the  anterior  abdominal  wall.  This  is  no  doubt  correct,  but  at  the  same 
time,  should  infection  of  the  uterine  wound  occur  with  the  former  inci- 
sion, virulent  material  is  more  liable  to  gain  access  to  the  general  peritoneal 
cavity;  while,  if  it  occurs  with  the  latter,  the  abscess  has  more  chance  of 
pening  through  the  abdominal  wound. 

No  matter  which  incision  has  been  employed,  it  is  then  closed  by  deep 
silk  and  snppi-fim'al  catgut  sntm-Pi-r  or,  if  preferred,  formol  catgut  may  be 
used  for  both.  The  former  are  inserted  at  intervals  of  about  1  centimetre, 
and  extend  through  the  entire  thickness  of  the  muscularis.  avoiding  the 
decidua.  They  are  then  tied,  and  if  accurate  approximation  is  not  secured, 
the"~gaping  margins  of  the  wound  are  brought  together  by  superficial  cat- 
gut sutures  which  extend  through  the  peritonaeum  and  the  upper'  layers  of 
the  muscularis.  Sanger  recommended  the  formation  of  a  small  flap  of 
peritonaeum  on  either  side  of  the  wound,  by  excising  a  thin  layer  of  mus- 
cularis from  its  margins  and  uniting  the  flaps  by  sero-serous  sutures.  This 
procedure,  however,  is  not  only  unnecessary,  but  also  considerably  prolongs 
the  operation.  Any  blood  which  may  have  escaped  into  the  pelvic  cavity  is 
then  carefully  sponged  out  and  the  abdominal  wound  closed.  This  is  best 
accomplished  by  suturing  the  peritonaeum,  muscles,  fascia,  and  skin  in 
separate  layers. 

(b)  Pjirro  C 'cesarean  Section. — Until  after  the  delivery  of  the  child,  the 
operative  steps  are  identicaFrrt  the  Porro  and  the  conservative  Caesarean 
section.  In  the  former,  however,  as  the  body  of  the  uterus  is  to  be  am- 
putated, it  is  unnecessary  to  remove  the  placenta.  As  soon  as  the  child 
is  delivered,  an  elastic  ligature  is  tightly  tied  around  the  upper  portion 
of  the  cervix.  The  mfimdibulo-pelvic  ligaments  are  then  ligated  and  cut 
through,  after  which  the  uterus  is  amputated  a  short  distance  above  the 
rubber  ligature.  To  prevent  the  stump  from  slipping  backward,  a  long, 
straight  needle  is  passed  through  it  and  allowed  to  rest  upon  the  abdominal 
walls.  The  stump  is  then  sewed  into  the  lower  angle  of  the  abdominal 
wound,  the  remainder  being  closed  in  the  usual  manner.  Within  a  short 
time  the  stump  and  elastic  ligature  slough  off,  leaving  a  depressed  wound 
which  heals  by  granulation.  This  operation  is  readily  performed,  but  is  I 
rarely  employed  at  present,  because  of  the  complicated  healing  necessary/ 
and  the  in-drawn  scar  which  results. 

Instead  of  the  typical  Porro  operation,  when  it  is  desirable  to  remove 
the  body  of  the  uterus,  the  stump  is  best  treated  as  in  an  ordinary  myo- 
mectomy. The  infundibulo-pelvic  and  round  ligaments  on  either  side  are 
ligatecl  at  their  distal  ends,  clamped  at  their  uterine  ends  and  severed. 
With  a  single  stroke  of  the  scissors,  the  broad  ligament  on  either  side  is 
cut  through  down  to  its  base.  An  elliptical  incision  is  then  made  through 
the  peritonaeum  on  the  anterior  surface  of  the  uterus,  just  above  the  blad- 
der, and  a  peritoneal  flap  rapidly  peeled  off  by  means  of  a  piece  of  gauze 
applied  around  the  end  of  the  finger  or  the  handle  of  a  scalpel.     The 


c.ESAUKAN'    SECTION   AND   SYMPHYSEOTOMY  I "7 

uterine  arteries  are  then  isolated,  Ligated,  and  Bevered,  after  which  the  body 
of  the  uterus  is  amputated.  The  peritonea]  flap  is  stitched  over  the  cervica] 
stump,  which  is  then  dropped  into  the  pelvic  cavity.  The  openings  in  the 
broad  Ligaments  are  then  closed  by  continuous  catgut  sutures,  the  pelvic 
cavity  is  sponged  out,  and  the  abdominal  wound  closed. 

The  operation  is  readily  performed,  and  can  he  completed  in  less  time 
than  is  required  for  an  ordinary  Caesarean  section;  for,  owing  to  the  laxness 
of  the  pelvic  floor  and  the  abdominal  walls,  the  upper  portion  of  the 
cervix  can  be  brought  through  the  incision  and  the  entire  operation  com- 
pleted upon  the  surface  of  the  abdomen  instead  of  in  the  depths  of  the 
pelvis. 

(c)  Total  Jf  i/kI  creel  o  mi/. — Bisehoff  was  the  first  to  remove  the  entire 
uterus  after  Caesarean  seel  ion,  and  at  the  present  time,  under  thoroughly 
aseptic  conditions,  the  operation  gives  satisfactory  results.  The  technique 
is  identical  with  that  employed  in  supravaginal  amputation  of  the  uterus, 
except  that  after  the  ligation  of  the  uterine  arteries  the  vaginal  vault  is  cut 
through  and  the  entire  uterus  removed,  after  which  the  opening  in  the 
vagina  is  closed  with  catgut  and  the  broad  ligament  wounds  are  sutured. 
Total  hysterectomy  is  rarely  indicated  except  in  cancer  of  the  uterus,  or  in 
the  occasional  cases  of  infection. 

Choice  of  Operation. — In  the  vast  majority  of  cases  the  conservative 
Caesarean  section  is  the  operation  of  choice,  as  it  is  readily  performed  and 
gives  most  satisfactory  results.  On  the  other  hand,  when  there  is  any 
possibility  of  infection,  complete,  or  at  least  supravaginal,  hysterectomy 
should  be  done.  When  the  uterus  is  the  seat  of  tumour  formation,  as  well 
as  in  those  cases  in  which  osteomalacia  is  the  cause  of  the  pelvic  deformity, 
or  in  which  persistent  haemorrhage  resulting  from  uterine  atony  compli- 
cates the  conservative  operation,  supravaginal  hysterectomy  is  the  operation 
of  choice. 

In  doing  a  Caesarean  section  the  question  often  arises  as  to  the  ad- 
visability of  sterilizing  the  patient  so  as  to  avoid  the  possibility  of  future 
conception.  This  can  be  effected  by  supravaginal  amputation  of  the  uterus, 
by  excising  the  tubes,  or  removing  the  ovaries. 

It  was  formerly  believed  that  sterilization  could  be  effected  by  ligating 
the  proximal  end  of  either  tube;  but  experience  has  shown  that  the  liga- 
tures eventually  cut  through  or  become  absorbed,  and  that  the  lumen  of 
the  tube  may  subsequently  become  restored,  and  with  it  the  possibility  of 
future  pregnancy.  It  was  next  suggested  that  the  object  might  be  accom- 
plished by  applying  a  double  ligature  to  each  tube  and  excising  the  por- 
tion between  them;  but  the  experiments  of  Fraenkel  upon  animals,  and  the 
experience  of  Zweifel  upon  the  living  woman,  have  shown  that  even  these 
measures  do  not  insure  against  conception,  since  the  ligatures  may  be  ab- 
sorbed and  the  cut  ends  of  the  tube  become  united.  In  order,  therefore, 
to  render  a  woman  permanently  sterile  by  an  operation  upon  the  tubes, 
they  must  be  excised  by  wedge-shaped  incisions  at  the  cornua  of  the  uterus 
and  the  wounds  closed  by  sutures.  When  this  is  to  be  done,  the  fundal 
incision  is  preferable,  as  it  can  readily  be  extended  to  the  cornua  of  the 
uterus  after  the  extraction  of  the  child. 


408  OBSTETRICS 

Sterilization  should  not  be  attempted  by  the  removal  of  the  ovaries,  for 
the  reason  that  the  retracting  uterus  may  exert  such  tension  upon  the  pedi- 
cles that  the  sutures  may  slip  and  fatal  haemorrhage  result.  Of  course  the 
woman  is  effectually  sterilized  after  supravaginal  amputation  or  total  hys- 
terectomy, but  in  most  cases  it  is  better  to  excise  the  tubes  and  leave 
the  uterus  and  ovaries,  in  order  that  the  patient  may  escape  the  inconve- 
niences attending  a  premature  menopause. 

The  opinion  of  those  authorities  who  consider  that  sterilization  should 
form  an  integral  part  of  every  Caesarean  section  is  certainly  open  to  ques- 
tion. If  the  patient  is  intelligent,  the  decision  should  be  left  to  her  or  her 
family;  whereas  withthe  ignorant  it  is  incumbent  upon  the  physician  to  do 
what  he  thinks  is  best  under  the  circumstances.  Personally,  I  should  be 
unwilling  to  sterilize  the  patient  at  the  first  operation,  unless  she  comes 
from  a  district  where"  proper  operative  help  might  not  be  available  in  a 
future  pregnancy.  On  the  other  hand,  if  she  is  weak-minded  or  diseased 
and  is  liable  to  require  repeated  Caesarean  sections  the  operation  is  per- 
fectly justifiable. 

Prognosis. — When  considering  the  history  of  Caesarean  section,  refer- 
ence was  made  to  the  mortality  attending  it  in  former  times.  Since  the 
rehabilitation  of  the  conservative  operation  by  Sanger  in  1882,  and  the 
constant  advance  in  aseptic  technique,  there  has  been  a  corresponding 
steady  improvement  in  the  results:  Caruso  collected  from  the  literature 
135  cases  which  had  been  performed  between  the  years  1882  and  1888,  with 
a  mortality  of  25.56  per  cent.  Since  then  the  death-rate  has  gradually 
fallen,  so  that  at  present  on  an  average  less  than  10  per  cent  of  the  women 
are  lost. 

Indeed,  in  the  hands  of  expert  operators,  still  more  favourable  results 
are  the  rule.  Thus,  Zweifel  has  performed  76  Caesarean  sections  with  1,  and 
Eeynolds  23  with  no  deaths.  In  335  operations  performed  by  Chrobak, 
Schauta,  Leopold,  Braun,  Olshausen,  Zweifel,  Eeynolds,  Bar,  Charles,  and 
Cragin,  there  were  only  23  deaths — a  gross  mortality  of  6.87  per  cent, 
which  becomes  reduced  to  4.06  per  cent  on  deducting  the  cases  which  were 
infected  prior  to  the  operation.  In  the  11  Caesarean  sections  performed  at 
the  Johns  Hopkins  Hospital  all  the  mothers  were  saved,  and  the  only  death 
in  our  clinic  followed  an  operation  performed  upon  a  coloured  woman  at 
her  own  home,  in  a  room  so  small  as  to  make  it  necessary  to  remove  the 
bed  in  order  to  find  space  for  the  operating  table.  Thus  it  will  be  seen  that 
the  mortality  following  the  conservative  Caesarean  section,  when  properly 
performed  upon  uninfected  patients  amid  good  surroundings,  should  hardly 
exceed  that  attending  the  removal  of  simple  ovarian  tumours.  On  the 
other  hand,  it  should  be  remembered  that  when  performed  by  inexperienced 
operators  upon  patients  in  poor  condition  and  amid  unhygienic  surround- 
ings, the  results  will  be  most  disastrous. 

The  typical  Porro  operation  and  the  supravaginal  amputation  of  the 
uterus,  with  retroperitoneal  treatment  of  the  stump,  have  shown  a  simi- 
lar improvement.  Thus,  441  Porro  operations  performed  up  to  the  year 
1891,  and  tabulated  by  Harris,  give  some  idea  of  the  rapid  decrease  in 
mortality.     From  1876  to  1881  there  were  95,  from  1882  to  1886,  148, 


c.KsaKKAN    SECTION    AND   SYMPHYSEOTOMY  409 

and  from  lss^   to  L891,  L98  operations,  with  a  mortality  of  60  per  cent, 

45  per  cent,  and  22.8  per  cenl  respectively.     During  the  sa period  the 

mortality  following  retroperitoneal  treatraenl  of  the  stump  was  reduced 
from  85.7  per  cent  to  H>.u  per  cent.  In  l^i  operations  recently  reported 
by  Chrobak,  Schauta,  Leopold,  and  Braun,  the  gross  mortality  was  L0.3 
per  rent,  which  became  reduced  to  2.5  per  cent  on  deducting  the  casee 
which  were  infected  prior  to  operation.  On  the  other  band,  when  per- 
formed upon  infected  patients,  no  matter  what  method  he  employed,  the 
results  of  the  operation  are  still  extremely  unsatisfactory,  Doktor,  of  Buda- 
pest, having  collected  22  such  cases,  with  a  mortality  of  23.5  percent. 

This  marvellous  diminution  in  the  mortality  is  due  to  several  factors. 
Primarily,  of  course,  it  must  be  attributed  to  the  ever-increasing  perfec- 
tion of  aseptic  technique.  At  the  same  time,  careful  examination  of  the 
pelvis  before  labour  and  the  determination  to  operate  while  the  patient  tis  in 
good  condition,  instead  of  only  after  the  failure  of  other  methods  of  delivery, 
have  contributed  markedly  to  the  improvement.  It  should  be  remembered 
that  the  best  results  are  obtained  when  the  operation  is  resorted  to  at 
the  end  of  pregnancy  or  at  the  onset  of  labour,  and  that  they  rapidly 
become  worse  the  later  in  the  second  stage  it  is  performed.  In  my  experi- 
ence convalescence  in  the  former  class  of  cases  is  uninterrupted,  while  in 
the  latter  it  is  usually  more  or  less  seriously  interfered  with. 

Repeated  ('cesarean  Section. — The  performance  of  conservative  Cgesarean 
section  does  not  interfere  with  future  conception,  as  is  shown  by  the  fact 
that  even  in  pfe-antiseptic  times  not  a  few  cases  were  reported  in  which 
the  same  woman  had  repeatedly  been  subjected  to  the  operation.  Leopold 
speaks  of  a  patient  upon  whom  he  operated  four  times,  while  Ahlfeld  and 
Birnbaum  have  reported  cases  of  women  who  underwent  five  Cesarean  sec- 
tions. The  statistics  of  Abel,  Bar,  and  Caruso  show  that  43  patients  had 
been  subjected  to  the  procedure  upon  two  or  more  occasions,  without  a 
death,  thus  apparently  indicating  that  a  subsequent  operation  is  even  better 
borne  than  the  first. 

The  occurrence  of  pregnancy  after  a  Cesarean  section,  however,  is  not 
always  devoid  of  danger,  as  "Woyer  and  Targett  have  reported  cases  in  which 
the  uterine  eir-a.triv  ruptured  in  the  latter  part  of  the  subsequent  gestation. 
This,  however,  is  a  very  unusual  occurrence.  It  is  also  stated  that  the 
adhesions  which  sometimes  form  between  the  uterus  and  the  anterior  ab- 
dominal wall  occasionally  exert  a  deleterious  influence  in  subsequent  preg- 
nancies. Aside,  however,  from  the  slight  discomfort  incident  to  their 
stretching,  no  serious  consequences  have  been  observed,  and  in  not  a  few 
cases  the  subsequent  operation  has  been  done  through  the  old  adhesions 
without  opening  into  the  general  peritoneal  cavity. 

Vaginal  Ccvsarean  Section. — By  this  name  Diihrssen  has  described  an 
operation  by  means  of  which  the  child  is  delivered  by  the  vagina  through 
an  incision  in  the  cervix  and  lower  uterine  segment.  This,  of  course,  is  only 
practicable  where  the  pelvis  is  approximately  normal,  and  the  indications 
are  therefore  quite  different  from  those  that  hold  good  in  the  cases  that 
have  just  been  considered. 

In  this  procedure  the  anterior  and  posterior  culs-de-sac  are  opened  and 


410  OBSTETRICS 

the  bladder  is  separated  from  its  connections,  after  which  an  incision  is 
made  through  the  cervix  and  lower  uterine  segment  sufficiently  large  to 
permit  the  extraction  of  the  child  by  version  or  forceps.  After  delivery  the 
wounds  are  closed  by  sutures,  or  in  other  cases  the  entire  organ  is  removed 
by  vaginal  hysterectomy.  Duhrssen,  in  1900,  collected  22  such  operations 
with  5  deaths,  the  majority  of  them  having  been  undertaken  for  car- 
cinoma of  the  cervix,  and  several  for  eclampsia.  The  operation  has  a  very 
limited  field  of  usefulness,  and  should  be  reserved  for  cases  complicated  by 
carcinoma,  in  which  it  is  desired  to  follow  delivery  by  vaginal  hysterectomy. 

Laparo-elytrotomy. — This  operation,  which  was  recommended  by  Baude- 
locque  in  1823,  and  rehabilitated  by  Gaillard  Thomas  in  1871,  aims  at  de- 
livering the  child  without  opening  the  peritoneal  cavity.  For  this  purpose 
an  oblique  incision  is  made  just  above  Poupart's  ligament  and  the  cervix 
reached  extraperitoneally.  After  its  exposure,  an  incision  is  made  into  it 
through  which  the  child  is  extracted.  This  operation,  while  useful  in  pre- 
antiseptic  times,  is  no  longer  employed,  inasmuch  as  better  and  more  cer- 
tain results  are  obtained  by  the  usual  methods  of  procedure. 

Post-mortem  C cesarean  Section. — From  the  earliest  times,  when  a  patient 
died  undelivered  in  the  neighbourhood  of  full  term,  Cgesarean  section  was 
sometimes  performed  immediately  after  her  death,  in  the  hope  of  saving 
the  life  of  the  child.  The  number  of  children  rescued  by  the  procedure, 
however,  has  always  been  very  small.  In  view  of  this  fact,  and  the  abhor- 
rence in  which  it  is  more  or  less  justly  held  by  the  laity,  I  do  not  consider 
that  it  should  be  recommended,  more  satisfactory  results  being  obtainable 
from  accouclxement  force,  especially  as  the  cervix  just  before  or  immediately 
after  death  is",molle  readily  dilatable  than  at  other  times. 

Symphyseotomy. — By  symphyseotomy  is  meant  the  division  of  the  pubic 
joint  in  order  to  bring  about  an  increase  in  the  capacity  of  a  contracted 
pelvis  sufficient  to  permit  the  passage  of  a  living  child. 

J.  B.  Sigault  first  performed  the  operation  in  17?  7,  and  thereby  suc- 
cessfully delivered  a  certain  Madame  Suchot,  of  Paris,  who  had  a  rhachitic 
pelvis  with  a  conjugata  vera  of  6.5  centimetres  and  had  previously  given 
birth  to  four  dead  children.  The  procedure  created  a  great  sensation, 
though  when  the  patient  was  exhibited  before  the  Faculty  of  Medicine 
two  months  later  she  walked  with  considerable  difficulty,  and  had  a  urinary 
fistula  from  which  she  never  recovered. 

The  operation  was  taken  up  with  great  enthusiasm,  and  was  performed 
upon  11  patients  within  the  first  year  after  Sigault's  report.  Opposition 
to  it,  however,  soon  developed,  Baudelocque  denouncing  it  as  a  "  murderous 
and  unphilosophical  procedure  ";  and  the  discussion  as  to  its  merits  waxed 
so  bitter  that  the  Parisian  physicians  became  divided  into  two  groups, 
Cesareans  and  S}miphyseans.  As  a  result  of  poor  technique  and  its  employ- 
ment in  unsuitable  cases,  symphyseotomy  soon  fell  into  disrepute  and  was 
forgotten  except  in  Italy,  where  it  was  performed  sporadically  until  the 
year  1858. 

The  operation  was  rehabilitated  in  1866  by  Morisani,  of  Xaples,  who 
obtained  very  satisfactory  results  by  its  means,  being  able  to  report  50 
operations  with  40  recoveries  to  the  International  Medical  Congress  in 


CESAREAN    SECTION    AND   SYMIMI YSKOTOM V 


411 


1881.  II  was  reintroduced  into  France  by  Spinelli  in  L891,  wlm  impressed 
its  merits  so  strongly  upon  Pinard  thai  he  tools  it  up  and  has  since  lum 
its  mosl  enthusiastic  advocate,  being  able  to  reporl  in  L900  thai  LOO  sym- 
physeotomies bad  been  performed  in  bis  clinic.  The  anatomical  aspect-  of 
symphyseotomy  were  carefully  studied  by  Farabeuf,  who  accurately  demon- 
strated its  theoretical  possibilities.  Dr.  Robert  P.  Harris  played  a  promi- 
nent part  in  directing  attention  to  the  operation  in  this  country  by  a 
paper  entitled  The  Remarkable  Results  of  Antiseptic  Symphyseotomy,  read 
at  the  1892  meeting  of  the  American  Gynecological  Society.  Stimulated 
by  tins  report,  Jewett,  a  few  years  later,  performed  the  first  operation  in 
America,  and  was  soon  followed  by  many  others.  Since  then  the  ques- 
tion of  symphyseotomy  has  been  a  burning  one,  and  was  the  main  theme  of 
discussion  at  the  German  Gynaecological  Congress  in  1893,  the  Interna- 
tional Medical  Congress  in  1897,  and  the  Obstetrical  Society  of  France 
in  1899. 

Effect  of  Si/niphi/senlniin/  upon  the  Size  of  the  Pelvis. — As  soon  as  the 
symphysis  is  cut  through,  the*  ends  of  the  pubic  bones  gape  from  3  to  6  cen- 
timetres.    Owing  to  the  structure  of  the  sacro-iliac  joints,  the  ossa  innomi- 


Fig.  402. — Diagram  showing  Effect  of  Symphyseotomy  (Farabeuf.). 


nata  flare  outward,  while  the  tips  of  the  pubic  bones  become  depressed 
downward.  As  a  result  of  these  changes  the  capacity  of  the  pelvic  canal 
becomes  considerably  increased,  particularly  in  its  transverse  and  oblique, 
and  less  so  in  its  antero-posterior  diameters.  It  is  usually  stated  that  the 
crmjno-ata  vera  becomes  2  millimetres  lonp-er  for  each  centimetre  of  sepaia- 
tion  at  the  symphysis.  As  the  latter  may  amount  to  6  or  6.5  centimetres 
without  imperilling  the  integrity  of  the  sacro-iliac  joints,  the  increase  would 
aggregate  12  or  13  millimetres. 

According  to  Farabeuf  this  estimate  is  not  strictly  correct,  as  the 


412  OBSTETRICS 

increase  varies  with  the  size  of  the  pelvis,  being  13  millimetres  when  the 
true  conjugate  measures  6  centimetres,  and  10  millimetres  when  it  meas- 
ures 9  centimetres.  This,  however,  does  not  represent  the  actual  en- 
largement of  the  superior  strait  from  an  obstetrical  point  of  view;  for,  as 
Farabeuf  has  pointed  out,  one  of  the  parietal  bosses  fits  into  the  opening 
between  the  gaping  pubic  bones,  thereby  considerably  increasing  the  space 
available  for  the  passage  of  the  head.  Doderlein  has  calculated  that  when 
the  pubic  bones  gape  6  to  7  centimetres  the  area  of  the  superior  strait 
is  increased  by  one  half. 

Indications. — The  field  of  usefulness  of  symphyseotomy  is  compara- 
tively limited.  *  It  is  available  only  when  the  conjugata  vera  exceeds  6.5 
centimetres,  since  in  smaller  pelves  the  increase  in  the  area  of  the  superior 
strait  will  not  be  sufficient  to  permit  the  passage  of  the  head.  Accordingly, 
the  operation  cannot  be  considered  as  a  substitute  for  Csesarean  section, 
except  in  a  few  cases  at  the  upper  limit  of  the  old  relative  indication.  Thus 
symphyseotomy  must  be  regarded  as  a  competitor  of  version,  high  forceps, 
[and  craniotomy,  or  with  Csesarean  section  for  the  broadened  relative 
[indication. 

As  the  operation  merely  enlarges  the  pelvis,  and  must  be  followed  by 
the  extraction  of  the  child  by  version  or  forceps,  it  is  apparent  that  an 
error  in  the  estimation  of  the  size  of  the  head  or  the  pelvis  may  lead  to 
very  untoward  results,  cases  having  been  reported  in  which  Csesarean  sec- 
tion or  craniotomy  became  necessary  to  effect  delivery  after  an  ill-chosen 
symphyseotomy.  Moreover,  the  operation  does  not  become  available  until 
the  cervix  is  completely  dilated,  or  is  so  softened  as  to  be  readily  dilatable 
before  delivery  is  attempted.  t)n  the  other  hand,  its  great  advantage  lies  in 
the  fact  that  it  can  be  resorted  to  after  some  hours  after  second-stage  pains, 
when  Xature  has  shown  nerseit  unequal  Lo  lite  Lash  uf  delivery — conditions1 
,  under  which  Cesarean  section  is  usually  contra-indicated. 

Although  Davis  and  Jewett  have  recommended  the  performance  of  the 
loperation  in  face  presentations  when  the  chin  is  posterior,  as  well  as  in  cer- 
tain impacted  posterior  occiput  presentations,  I  know  of  no  cases  in  which 
it  has  been  undertaken  for  such  indications. 

The  operation  is  contra-indicated  when  one  or  both  sacro-iliac  joints 
are  ankylosecl,  as  under  such  circumstances  the  iliac  bones  eaillioi— become 
flared  outward;  although  Pinard,  in  a  case  of  Xaegele  pelvis,  performed  a 
modified  operation — isch io-p ubioto m y— with  success.  Moreover,  symphys- 
eotomy, is  a  questionable  procedure  when  the  patient  is  profoundly  in- 
fected. I  cannot  agree  with  Jewett  and  others  that  it  is  permissible  under 
such  circumstances,  as  I  consider  that  better  results  will  be  obtained  from 
craniotomy;  or,  if  the  patient  be  extremely  desirous  of  having  a  living 
child,  from  Cesarean  section  followed  by  total  hysterectomy. 

Method  of  Operating. — The  patient  should  lie  upon  her  back  with  her 
buttocks  at  the  edge  of  the  table.  After  the  external  genitalia,  Mons 
Veneris,  and  lower  portion  of  the  abdomen  have  been  shaved  and  cleaned 
as  carefully  as  for  an  abdominal  operation,  everything  except  the  Mons 
Veneris  and  lowest  portion  of  the  abdomen  should  be  covered  with  sterile 
towels.     An  incision  is  made  in  the  middle  line  from  a  |gw  centimetres 


I  .KSAUKAN    SECTION    AND   SYMPHYSEOTOMY  U3 

above  the  apper  margin  of  the  Bymphysis  almost  fco  Its  Lower  margin,  ex- 
tending through  the  skin  and  subcutaneous  fat  down  to  the  fascia  upon  its 
anterior  surface.    A  finger  is  passed  behind  the  symphysis  and  separates  the 

umlt 'Hying  tissues  until  its  Lower  margin  is  perfectly  free.  This  step  is 
frequently  accompanied  by  profuse  haemorrhage  from  the  aatevesicaj 
plexus.  The  attachments  of  the  clitoris  to  the  Lower  margin  olTthe  sym- 
physis are  then  separated  by  blunt  dissection,  after  which  a  catheter  is 
passed  into  the  urethra  and  pushes  it  downward  and  to  one  side.  The  pubic 
cartilage  is  then  cut  through  with  a  strong  knife,  either  from  its  anterior 
or  posterior  surface.  In  the  latter  case,  a  blunt-pointed  bistoury  is  passed 
behind  the  symphysis  ami  the  section  made  from  below  upward. 

In  manv  cases  the  pubic  bones  do  not  spring  apart  after  the  symphysis 
has  been  cut  through,  being  held  in  position  by  the  strong  subpubic  liga- 
ment, although  as  soon  as  this  has  been  isolated  and  severed  they  will 
gape  several  centimetres.  They  should  not  be  allowed  to  separate  more  than 
(i  centimetres,  any  tendency  towards  excessive  gaping  being  counteracted  by 
flexing  the  thighs  upon  the  abdomen  and  having  an  assistant  make  firm 
pressure  upon  the  trochanters.  Following  section  of  the  symphysis,  there 
is  usually  a  profuse  venous  haemorrhage,  which  is  best  controlled  by  pack- 
ing the  wound  with  sterile  ganze.  clamps  and  ligatures  not  being  available. 

After  symphyseotomy,  the  child  should  be  delivered  by  forceps  or  ver- 
sion, according  to  circumstances.  During  the  extraction,  firm  pressure 
should  be  made  upon  the  trochanters  on  either  side  to  prevent  too  wide  a  j 
separation  of  the  symphysis  and  consequent  injury  to  the  sacro-iliac  joints. 
Owing  to  the  fact  that  the  anterior  vaginal  wall,  bladder,  and  clitoris  have 
been  deprived  of  their  natural  support,  they  are  exposed  to  considerable 
tension  and  may  be  torn  through  if  excessive  force  is  employed.  By  adduct- 
ing  the  thighs  after  delivery  of  the  child,  the  ends  of  the  pubic  bones  are 
brought  together,  so  that  the  ligamentous  structure"  "p™  f1lp^  qntPT-inj- 
surface  can  be  united  by  mattress  or  figure-of-eight  sutures,  and  the  external 
wound  closed  in  the  usual  manner. 

Ayres  recommends  that  the  operation  be  performed  subcutaneously 
by  making  a  small  incision  immediately  over  the  clitoris  through  which  a 
blunt-pointed  knife  is  introduced,  the  symphysis  being  divided  from  behind 
forward  and  from  below  upward.  This,  however,  does  not  appear  an  ad- 
visable procedure,  as  it  precludes  the  possibility  of  suturing  the  symphysis 
and  of  successfully  checking  haemorrhage. 

After  the  completion  of  the  operation,  the  wound  should  be  covered 
with  sterile  dressings  and  a  broad  strap  of  canvas  applied  over  the  tro- 
chanters and  tightly  buckled,  the  latter  being  well  padded  with  cotton 
to  avoid  injurious  pressure.  The  after-treatment  is  extremely  compli- 
cated and  onerous.  Frequent  catheterization  is  necessary,  and  the  patient 
must  lie  on  her  back  for  three  or  four  weeks  after  the  operation.  During 
this  period  it  is  well  to  re-enforce  the  action  of  the  pelvic  strap  by  placing 
the  patient  in  a  hammock  bed,  especially  devised  for  the  purpose,  or  by 
allowing  the  pelvis  to  rest  upon  two  sand-bags. 

Prognosis. — Contrary  to  the  usual  statements,  my  experience  leads  me 
to  consider  that  symphyseotomy  is  a  very  serious  operation,  and  one  not 


414  OBSTETRICS 

to  be  lightly  undertaken.  In  many  cases  the  haemorrhage  is  exceedingly 
profuse  and  is  calculated  to  disconcert  an  inexperienced  operator.  More- 
over, the  vaginal  tears  frequently  extend  through  to  the  retropubic  wound, 
and  are  not  easy  to  repair.  Occasionally  the  bladder  is  injured  by  the  sharp 
end  of  one  of  the  pubic  bones,  while  more  frequently  the  clitoris  is  wounded 
and  gives  rise  to  alarming  haemorrhage.  Such  lesions  should  be  repaired 
immediately,  so  as  to  avoid  communication  between  the  vagina  and  the 
pubic  wound,  or  the  formation  of  urinary  fistulas.  If  errors  in  technique 
have  occurred  during  the  operation,  or  the  patient  be  already  infected,  the 
process  may  extend  to  the  pubic  wound  and  lead  to  destructive  suppura- 
tion. 

Considerable  apprehension  has  been  expressed  as  to  the  possibility  of 
failure  of  union  at  the  symphysis  pubis,  and  several  cases  have  been  re- 
ported by  Mullerheim  wnich  serve  to  show  that  the  operation  may  perma- 
nently maim  the  patient.  Fortunately,  such  accidents  are  extremely  rare; 
although  the  recent  investigations  of  Varnier  by  means  of  the  Eontgen 
ray  show  that  there  is  greater  motility  at  the  symphysis  than  before  the 
operation,  the  pubic  bones  being  united  by  a  mass  of  fibrous  tissue  several 
centimetres  wide.  This  does  not  necessarily  lead  to  disturbances  of  locomo- 
tion, but  the  patients  find  that  they  tire  more  readily,  and  are  less  able  to 
perform  hard  labour,  than  before  the  operation. 

It  appears  that  symphyseotomy  is  sometimes  followed  by  a  slight  but 
permanent  increase  in  the  size  of  the  pelvis,  which  is  sometimes  sufficient 
to  permit  spontaneous  labour  in  subsequent  pregnancies.  A  number  of 
such  instances  have  recently  been  collected  by  Madame  Wulff. 

The  analysis  by  JSTeugebauer  of  278  symphyseotomies  indicated  a  ma- 
ternal mortality  of  11.1  per  cent,  while  in  the  100  cases  operated  upon  in 
Pinard's  clinic  there  were  12  maternal  deaths;  and  even  after  deducting  a 
number  of  instances  in  which  he  considered  that  the  fatal  termination  was 
due  to  other  causes,  the  mortality  was  as  high  as  5  per  cent.  Bar,  basing 
his  conclusions  upon  140  operations  performed  by  himself,  Pinard,  Zweifel, 
and  Kiistner,  estimates  the  death-rate  at  6.7  per  cent.  On  the  other  hand,. 
Zweifel  has  operated  31  times  without  a  death.  The  foetal  mortality  was 
13  per  cent  in  Pinard's,  and  9.39  per  cent  in  Bar's  cases. 

On  comparing  the  results  following  symphyseotomy  and  Cesarean  sec- 
tion in  the  same  class  of  cases,  it  would  appear  that  little  can  be  said  in . 
favour  of  the  former.  In  the  first  place,  the  maternal  mortality  following 
it  equals,  if  it  does  not  exceed,  that  following  Caesarean  section,  while 
the  foetal  mortality  is  considerably  greater,  being  9  or  10  per  cent  in  the 
former  and  practically  nothing  in  the  latter  operation.  Moreover,  if  an 
error  is  made  in  estimating  the  relative  size  of  the  head  and  pelvis,  the 
child  is  inevitably  lost  with  symphyseotomy,  while  such  an  error  is  a 
matter  of  no  consequence  when  Caesarean  section  is  done.  Furthermore, 
there  is  no  comparison  as  regards  convalescence  following  the  two  opera- 
tions. After  the  former  the  patient  requires  prolonged  rest  in  bed  in  an 
uncomfortable  position,  whereas  after  the  latter  she  recovers  in  a  short  time 
and  with  but  slight  inconvenience. 

Abel  has  compared  the  results  obtained  in  25  symphyseotomies  and  50 


CESAREAN   SECTION    AND   SYMPHYSEOTOMY  415 

Caesarean  sections  performed  in  Zweifel's  clinic  There  were  no  maternal 
deaths  after  either  operation.  He  found  thai  the  convalescence  was  much 
more  rapid  and  comfortable  after  the  latter;  and,  what  Is  more  important, 
three  to  five  weeks  only  were  required  before  the  patient  was  able  to  take 
up  again  her  ordinary  duties  after  it,  as  compared  with  thirteen  weeks 
after  symphyseotomy. 

Oik-  of  the  chief  advantages  which  is  claimed  for  symphyseotomy  is 
that  it  tan  be  readily  performed  by  the  general  practitioner  in  unfavour- 
able surroundings,  and  even  upon  infected  patients;  while  Caesarean  section 
requires  considerable  operative  ability,  the  most  rigid  aseptic  technique, 
and  ideal  surroundings.  1  cannot  subscribe  to  such  an  opinion,  as  1  believe- 
that  the  same  requirements  must  be  fulfilled  to  insure  success  after  either 
operation.  Of  the  two  1  consider  symphyseotomy  the  more  difficult,  and 
do  not  believe  that  either  should  be  attempted  upon  infected  patients.  Bar, 
after  a  considerable  experience  with  the  two  operations — 22  symphyseoto- 
mies and  10  Caesarean  sections — has  concluded  tbat  the  latter  is  decidedly 
preferable,  and  that  the  field  for  the  former  is  very  limited.  At  the  1899 
meeting  of  the  Obstetrical  Society  of  France  similar  views  were  expressed 
by  Budin,  Charles,  and  others.  Personally,  at  the  present  time,  I  do  not 
expect  to  perform  symphyseotomy  under  any  circumstances,  and  consider 
that  the  present  enthusiasm  for  it  will  eventually  disappear. 


LITERATURE 

Abel.     Vergleich  cler  Pauererfolge  nach  Symphyseotomie  und  Sectio  Caesarea.     Archiv 

f.  Gyn.,  1899,  Iviii.  294-367. 
Ahlfeld.     Lehrbuch  der  Geburtshiilfe.  II.  Ann*..  1898.  547. 
Ayres.     Symphyseotomy,  etc.     N.  Y.  Polyclinic.  1896,  vii,  129-139. 
Bar.     De  Foperation  Cesarienne  conservative,  etc.     L'Obstetrique,  1899.  iv.  193-230. 
La  symphvseotomie.     Ses  resultats  immediates  et  eloignes,  etc.    L'Obstetrique.  1899, 

iv."  305-384. 
Lecons  de  pathologie  obstetrieale.     Paris.  1900. 
Baudelocque,  A.      Xouveau  procede  pour  pratiquer  l'operation  Cesarienne.     These  de 

Paris.  1823. 
Baudelocque.  J.  L.     De  la  section  du  pubis.     L'art  des  accouchements,  nouv.  ed.,  1789, 

ii.  461-561. 
Bauhin.     'yo-TepoTo/jATOKia.     Fr.  Rousseti,  etc.     Basil.  1588. 
Birxbaum.     5  Kaiserschnitte  bei  einer  Person.     Archiv  f.  Gym.  1885.  xxv.  422. 
Bischoff.     Die  totale  Exstirpation  des  schwangeren  und  careinomatosen  Uterus.     C'or- 

respondenzbl.  i.  Sehweizer  Aerzte,  1880.  Xr.  6. 
Braux-Ferxwald.     Ueber  den  in  den  letzten  10  Jahren  ausgefiihrten  Sectiones  Caesareae, 

Archiv  f.  Gym.  1899.  lix.  320-404. 
Bunrx.     Tarnier  et  Budin.  Traite  de  l'art  des  accouchements.  1901.  iv.  495. 
Budin  et  Demelix.     Symphyseotomie.     Tarnier  et  Budin.  Traite  de  l'art  des  accouche- 
ments. 1901.  iv.  456-489. 
Caruso.     Die  nenesten  Ergebnisse  des  conservativen   Kaiserschnittes  mit  Uterusnaht. 

Archiv  f.  Gym.  1888,  xxxiii.  211-269. 
Charles.    Parallele  entre  les  diverses  operations  a  pratiquer  dans  les  vices  du  bassin. 

L'Obstetrique.  1899.  iv.  280-2*6. 
Chrobak.     Quoted  by  Braun-Fernwald. 


416  OBSTETRICS 

Ceagin.  Cesarean  Section.  Medical  Record,  1901,  lix,  659-701  (May  4,  1901). 
Davis.  The  Management  of  Face  Presentation.  Medical  News,  July  14,  1894. 
Doderlein.     Exp.  anat.  Untersuchungen  iiber  die  Symphyseotomie.     Verh.  d.  deutschen 

Gesell.  f.  Gyn.,  1893,  v,  27-34. 
Doktor.     Kaiserschnitt  bei  Sepsis.     Archiv  f.  Gyn.,  1899,  lix,  200-216. 
Duhrssen.     Der  vaginale  Kaiserschnitt.     Berlin,  1896. 

Ein  neuer  Pall  von  vaginalen  Kaiserschnitt,  etc.     Archiv  f.  Gyn.,  1900,  lxi,  548-564. 
Farabeuf.     Sur  la  symphyseotomie.     Annales  de  Gyn.  et  d'Obst.,  1894,  xli,  407-431. 
Felkin.     Quoted  by  Ploss.     Das  Weib  in  der  Natur-  und  Volkerkunde,  IV.  Aufl.,  1895,  ii, 

297. 
Fraenkel,  L.     Experimente  zur  Herbeif iihrung  der  Unwegsamkeit  der  Eileiter.     Archiv 

f.  Gyn.,  1899,  lviii,  374-410. 
Fritsch.     Ein  neuer  Schnitt  bei  der  Sectio  Caesarea.     Centralbl.  f.  Gyn.,  1897,  561-565. 
Hahn.     11  konservative  Kaiserschnitte  mit  querem   Fundalschnitt.     Centralbl.  f.  Gyn., 

1899,  1457-1476. 
Halbertsma.     Eclampsia  gravidarum.      Eine   neue   Indikationsstellung  fur  die   Sectio 

Caesarea.     Centralbl.  f.  Gyn.,  1889,  901. 
Harris.     Remarks  on  the  Caesarean  Operation.     Amer.  Jour.  Obst.,  1879,  xi,  620-626. 
Cattle-horn  Lacerations  of  the  Abdomen  and  Uterus  in  Pregnant  Women.    Amer.  Jour. 

Obst.,  1887,  xx,  673-685,  and  1033. 
Results  of  the  Porro  Caesarean  Operation  in  all  Countries.     British  Med.  Jour.,  1890> 

i,  68. 
The  Remarkable  Results  of  Antiseptic  Symphyseotomy.     Trans.  Amer.  Gyn.  Soc,  1892, 

xvii,  98-126. 
The  Porro  Caesarean  Section  tested  by  a  Trial  of  Sixteen  Years,  etc.     jST.  Y.  Jour,  of  Gyn. 

and  Obst.,  1893,  iii,  273-283. 
Hirst.     The  Comparative  Value  of  Cceliohysterotomy  and  Cceliohysterectomy  in  Cases 

requiring  Caesarean  Section.     Amer.  Jour.  Obst.,  1898,  xxxvii,  577-584. 
Holzapfel.     Kaiserschnitt  bei  Mastdarmkrebs.     Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1899, 

ii,  59-77. 
Hubl.     Ueber  dem  queren  Fundussehnitt  nach  Fritsch.     Monatsschr.  f.  Geb.  u.  Gyn., 

1899,  417-432. 
Jewett.     A  Case  of  Symphyseotomy.     Brooklyn  Med.  Jour.,  1892,  vi,  790-792. 

The  Place  of  Symphyseotomy  as  contrasted  with  Caesarean  Section.     Amer.  Med.,  1901, 

September  28,  488-489. 
Lebas.     Jour,  de  Med.  et  de  Chirurgie,  1770,  xxxiv  (supplement). 
Leopold   und  Haake.      Ueber  100   Sectiones   Caesareae.      Archiv  f.   Gyn.,   1898,  liv, 

1-41. 
Litzmann.     Kaiserschnitt  mit  temporarer  Ligatur  des  Cervix.     Centralbl.  f.  Gyn.,  1879, 

289-295. 
Meyer.     Sulla  gastroisterotomia.     Napoli,  1867. 

Morisani.     De  la  symphyseotomie.     Annales  de  Gyn.  et  d'Obst.,  1881,  xvi,  444-445. 
Mullerheim.     Die  Symphyseotomie.     Volkmann's  Sammlung  klin.  Vortrage,  1894,  Nr. 

91,  1-54. 
Neugebauer.     Ueber  die  Rehabilitation  der  Sehamfugentrennung,  etc.     Leipzig,  1893. 
Olshausen.     Kaiserschnitt    wegen   Eklampsie.      Zeitschr.   f.   Geb.    u.    Gyn.,    1900,   xlii, 

348-351. 
Ueber  den  Kaiserschnitt  und  seine  Indikation  bei  Beckenverengerung.     Zeitschr.  f. 

Geb.  u.  Gyn.,  1897,  xxxvii,  533-541. 
Pinard.     De  la  symphyseotomie.     Annales  de  Gyn.  et  d'Obst.,  1892,  xxxvii,  81-94. 

Indication  de  l'operation  cesarienne  consideree  en  rapport  avec  celle  de  la  symphyseo- 
tomie, etc.     Annales  de  Gyn.  et  d'Obst,  1899,  lii,  81-117. 
Du  soi-disant  foeticide  therapeutique.     Annales  de  Gyn.  et  d'Obst.,  1900,  liii,  1-18. 
Porro.     Delia  araputazione  utero-ovarica,  etc.     Milan,  1876. 


CESAREAN  SECTION  AXD  SYMPHYSEOTOMY  417 

Reynolds.    Circumstances  which  render  the  Elective  Section  Justifiable  in  the  Interest  of 

the  Child  Alone.     Amer.  Med.,  L901,  ii,  489-493,  September  28. 
Rousset.     Traite  nouveau  de  l'hysterotomotokie  on  l\-n t'ani enicnt.  eesarien.     Paris,  15M. 
Sam;i:k.     Der  Kaiserschnitl  bei  Qterusmyomen,  etc.    Leipzig,  1882. 
Schauta.    Quoted  by  Braun-Fernwald. 
Schroeder,  11.    Zur  Kaiserschnittsfrage.    Monatsschr.  E.  Geb.  u.  Gyn.,  l'JOi.xiii,  22-39, 

und  206-230. 
Sm.uLT.     Discours  sur  les  avantages  de  la  section  de  la  symphyse  dans  Les  accouche- 

ments,  etc.     Paris,  1779. 
Spinelli.     Les  resultats  de  la  symphyseotomie,  etc.     Annales  de  Gyn.  et  d'Obst.,  1892, 

xxx vii,  2-15. 
Storeu.     Extirpation  of  the  Puerperal  Uterus  by  Abdominal  Section.     Jour.  Gyn.  Soc.  of 

Boston,  1801,  i.  22:!. 
Targett.     Rupture  of  Uterus  in  Old  Cesarean  Section  Cicatrix.     Trans.  Lond.  Obst.  Soc, 

1900,  p.  242. 

Thomas,     Gastro-elytrotomy  :  A  Substitute  for  the  Cesarean  Section.     Amer.  Jour.  Obst., 

1871.  iii,  123-139. 
Trautmaxx.     See  Siebold,  Versueh  einer  Geschicht  der  Geburtshiilfe,  1845,  ii.  108-111. 
Trixks.     Xeue  Kaiserschnittfragen,  Fundalschnitt,  etc.     Hegar's  Beitrage  zur  Geb.  u. 

Gyn.,  1898,  i,  449-469. 
Varxier.     Etude  anat.  et  radiographicme  de  la  symphyseotomie.     Comptes  rendus  de  la 

Soc.  d'Obst,,  de  Gyn..  et  de  Ped.  de  Paris,  1899,  i,  208-243. 
Williams.     Pelvic  Indications  for  the  Performance  of  Cesarean  Section.     Amer.  Med., 

1901,  September  28 ;  Trans.  Amer.  Gyn.  Soc,  1901,  xxvi,  260-276. 

Woyer.     Ein  Fall  von  Spontanruptur  des  schwangeren  Uterus  in  der  alten  Kaiserschnitts- 

narbe.     Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  vi,  192-200. 
Zweifel.     Ueber  Symphyseotomie.     Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  vi,  227. 

Referred  to  by  Abel. 

Quoted  by  Braun-Fernwald. 


CHAPTER  XXIII 

DESTRUCTIVE   OPERATIONS 

Craniotomy. — Under  this  heading  are  included  all  operations  which 
"bring  about  a  decrease  in  the  size  of  the  foetal  head,  with  a  view  to  ren- 
dering its  delivery  easier. 

Prior  to  the  introduction  of  podalic  version  and  forceps,  artificial  de- 
livery could  be  effected  only  by  means  of  craniotomy  or  embryotomy,  one 
or  other  of  which  was  resorted  to  in  nearly  every  case  of  difficult  labour. 
Accordingly,  in  former  times,  the  perforator,  sharp  hook,  and  crotchet  were 
the  most  important  instruments  in  the  obstetrician's  armamentarium.  In- 
creased dexterity  in  the  employment  of  forceps  and  version,  however, 
brought  about  a  rapid  change,  and  craniotomy  upon  the  living  child  became 
rarer  and  rarer. 

Indications. — Craniotomy  is  positively  contra-indicated  when  the  con- 
jugata  vera  measures  less  than  5.5  centimetres,  since  in  such  cases  the 
extraction  of  the  child,  even  after  the  skull  has  been  crushed,  is  attended 
by  a  greater  maternal  mortality  than  Cesarean  section.  On  the  other  hand, 
in  pelves  above  this  limit,  craniotomy  may  be  indicated  under  any  condi- 
tions that  render  the  delivery  of  a  mutilated  child  the  most  conservative 
procedure,  so  far  as  the  safety  of  the  mother  is  concerned. 

The  indications  for  its  performance  vary  markedly.  When  the  child  is 
dead  craniotomy  is  indicated  whenever  it  will  render  delivery  easier,  and 
is  preferable  to  forceps  or  version  unless  those  operations  can  be  undertaken 
without  'detriment  to  the  mother.  ^Esthetic  considerations  should  never 
deter  the  operator  from  resorting  to  it.  On  the  other  hand,  if  the  child 
is  alive,  the  operation  is  justifiable  only  in  exceptional  cases;  indeed, 
Pinard  and  some  others  hold  that,  in  view  of  the  satisfactory  results  ob- 
tained from  symphyseotomy  and  Caesarean  section,  it  should  never  be  per- 
formed. This,  however,  must  be  looked  upon  as  too  radical  a  view  and  one 
demanding  a  certain  amount  of  qualification;  for,  although  it  must  ever  be 
the  duty  of  the  obstetrician  to  do  his  best  to  save  the  life  of  both  mother 
and  child,  it  is  nevertheless  readily  conceivable  that  conditions  may  arise 
under  which  craniotomy  upon  the  living  child  may  not  only  be  perfectly 
justifiable,  but  even  imperatively  demanded. 

Generally  speaking,  craniotomy  should  not  be  performed  upon  the  living 
child  if  the  mother  is  in  good  condition,  amid  suitable  surroundings,  and 
in  the  hands  of  a  competent  operator.  Under  such  circumstances,  if  the 
418 


DESTRUCTIVE  OPERATIONS  I  L9 

obstacle  io  labour  bo  due  to  a.  contracted  pelvis  or  an  excessively  Large 
child,  Caesarean  section  is  preferable,  inasmuch  as  the  slightly  increased 
risk  to  the  mother  is  more  than  compensated  for  by  the  rescue  of  her  off- 
spring.   On  il ther  hand,  if  the  woman  is  no1  seen  until  she  has  been 

in  the  second  stage  of  labour  Eor  a  considerable  time,  and  has  been 
subjected  to  repeated  vaginal  examinations  and  possibly  presents  signs 
of  infection,  Caesarean  section  is  aol  indicated,  hut  the  child  should  be 
sacrificed  in  the  interests  of  the  mother,  inasmuch  as  the  maternal  mor- 
tality attending  ( Isesarean  seel  ion  [iw<\rv  such  circumstances  is  in  the  neigh- 
bourhood of  25  per  cent.  Again,  if  the  child  is  not  in  good  condition, 
as  shown  by  a  too  rapid  or  too  slow  heart-beat,  or  by  the  passage  of  consider- 
able quantities  of  meconium  with  a  vertex  presentation,  its  life  is  already 
in  such  peril  that,  against  that  of  the  mother,  it  is  no  longer  entitled  to 
serious  consideration. 

Moreover,  in  country  districts,  where  the  physician  is  unable  to  sum- 
mon sufficient  assistance,  and  is  without  the  necessary  appliances  for  am 
aseptic  abdominal  operation,  Caesarean  section  should  not  be  undertaken 
and  craniotomy  becomes  the  operation  of  choice.  But  even  under  these 
adverse  conditions  the  latter  operation  should  be  deferred  as  long  as  pos- 
sible, and  should  not  be  resorted  to  until  delivery  becomes  imperative  in 
the  interests  of  the  mother,  and  then  only  after  the  failure  of  forceps. 

Hydrocephalus  affords  a  positive  indication  for  craniotomy,  which 
should  be  performed  as  soon  as  the  cervix  is  completely  dilated.  In  these 
cases  spontaneous  labour  is  out  of  the  question,  and  even  a  successful 
Csesarean  section  will  only  give  us  a  child  that  is  doomed  to  die  shortly  or 
remain  an  idiot. 

When  insuperable  obstacles  are  encountered  during  the  extraction  of 
the  after-coming  head,  craniotomy  is  a  justifiable  procedure,  since  the  child 
is  already  dead,  or  dies  within  a  few  minutes  after  the  nature  of  the  ob- 
stacle has  been  recognised,  and  before  preparations  can  be  made  for  its  de- 
livery by  symphyseotomy. 

Craniotomy  should  not  be  performed  until  the  external  os  has  become 
completely  dilated,  as  the  imperfectly  opened  canal  may  offer  a  serious 
obstacle  to  the  extraction  of  the  child. 

Method  of  Operating. — The  patient  should  be  brought  to  the  edge  of 
the  bed  or  table,  placed  in  the  lithotomy  position,  and  prepared  as  for  an 
ordinary  obstetrical  operation.  Craniotomy  usually  includes  two  steps: 
first,  the  pav-f^ri3*-;™-!  nf  the  head  ;ind  the 
evar-nation  of  it<  fnntp]][i'  and,  Secondly, 
the  extraction  of  the  mutilated  child 

Numerous  instruments  have  been  de-    K^J1 
vised  for  perforating  the  head,  the  most  FlG.  403.-Smellie's  Scissors. 

suitable  of  which  are  Smellie's  scissors 

or  Blot's  perforator.  Braun  s  trepan  would  serve  the  purpose  admirably, 
but  is  not  to  be  recommended  on  account  of  the  difficulty  with  which  it  is 
kept  clean. 

If  the  head  is  engaged  and  firmly  fixed,  perforation  is  accomplished  with 
but  little  difficulty.     With  two  fingers  the  large  or  small  fontanelle,  as 
28 


420 


OBSTETRICS 


may  be  most  convenient,  is  located,  and  the  perforator  plunged  through  it. 
The  opening  is  then  enlarged  and  the  instrument  briskly  moved  about 
within  the  skull,  so  as  to  disintegrate  the  brain  to  such  an  extent  that  it 
can  be  washed  out  with  a  douche  of  sterile  water. 

|  If,  however,  the  head  is  movable  above  the  superior  strait,  it  must  be 
[firmly  fixed  by  means  of  pressure  exerted  by  an  assistant  through  the 
abdominal  walls.  To  avoid  wounding  the  maternal  soft  parts,  the  per- 
foration should  be  made  through  the  portion  of  the  head  lying  in  the  neigh- 
bourhood of  the  symphysis  pubis;  for,  should  the  instrument  slip  from  this 
position,  it  is  less  liable  to  inflict  serious  injury  than  if  it  were  near  the 
sacrum.  In  face  presentations  perforation  should  be  effected  through  the 
brow. 


' 

/ ' Jl 

/  m  -  k 

! 

(<•'-;-.- 

.  ^^ 

,: .  S 

^~:~ — 

V   ■  \ 

Kzfy 

y-         ^ 

^~**0;. 

T? 

i 

Fig.  404. — Method  of  Perforating  Head  (American  Text-Book). 

To  pierce  the  after-coming  head,  the  body  of  the  child  should  be  de- 
pressed and  the  instrument  carried  into  the  skull  in  the  neighbourhood  of 
the  temporal  suture.  If,  as  occasionally  happens,  this  point  cannot  be 
reached,  the  body  of  the  child  should  be  carried  up  over  the  abdomen  of 
the  mother,  and  perforation  effected  through  the  mouth  and  base  of  the 
skull.  When  a  hydrocephalic  child  presents  by  the  breech,  and  the  head 
is  arrested  at  the  pelvic  brim,  the  fluid  contents  of  the  skull  may  be  evacu- 
ated by  cutting  through  the  arch  of  one  of  the  cervical  vertebrae,  after 
which  a  metallic  catheter  is  passed  through  the  opening  and  carried  along 
the  vertebral  canal  into  the  skull. 

After  the  brain  has  been  washed  out,  although  the  vault  of  the  cranium 
collapses  and  offers  no  further  obstacle  to  labour,  the  base  of  the  skull  still 
remains  unchanged,  and  as  the  bimastoid  diameter  measures  between  7  and 
7.5  centimetres,  it  is  apparent  that  it  cannot  be  delivered  through  a  mark- 
edly contracted  pelvis  until  it  has  been  diminished  in  size. 

When  the  conjugata  vera  exceeds  7.5  centimetres,  the  collapsed  head 
may  be  expelled  by  the  uterine  contractions  alone,  or  may  be  extracted  by 
means  of  the  forceps  or  a  finger  introduced  through  the  perforation  open- 
ing.    But  even  in  pelves  of  this  size  it  is  usually  advisable  to  make 


DESTRUCTIVE  OPERATIONS 


421 


use  of  a  special  instrument  for  grasping  and  crushing  the  base  of  the 
skull.  The  cranioclastj  invented  by  Simpson  and  modified  by  Car] 
Brau  n,  serves  The  purpose  most   satisfactorily.     One  blade  is  introduced 


Fig.  405. — Braun's  C'ranioclast. 


through  the  perforation  until  its  free  end  impinges  upon  the  base  of  the 
skull,  while  the  fenestrated  blade  is  applied  over  the  face  or  lower  portion 
of  the  occiput.  The  vise  at  the  end  of  the  instrument  is  then  tightened,  and 
as  a  result  not  only  is  the  base  of  the  skull  more  or  less  compressed,  but  at 
the  same  time  a  firm  hold  is  obtained  for  the  extraction  that  is  to  follow. 

For  crushing  and  extract- 
ing the  head,  Baudelocque  the 
younger  invented  the  cepliah- 
tribe.  This  is  essentially  a 
very  heavy  forceps,  whose 
blades  come  closely  together 
and  forcibly  compress  the  head 
when  the  vise  at  the  ends  of 
the  handles  is  tightened.  The 
instrument  has  been  subjected 
to  many  modifications,  one  of 
the  best  being  that  of  Tarnier 
(Fig.  407).  At  the  same  time  it 
labours  under  the  disadvantage 
that  it  aims  to  accomplish  two 
purposes — i.  e.,  crushing  and 
extracting  the  head;  and,  un- 
fortunately, whenever  it  is  so 
constructed  as  to  be  an  effi- 
cient crusher  it  is  a  poor 
tractor,  and  vice  versa.  For 
these  reasons  the  cephalotribe, 
as  such,  is  but  little  used. 

Tarnier,  in  1883,  invented 
the  basiotribe,  a  three-bladed 
instrument  which  combines  in 
one  the  advantages  of  the  perforator,  cranioclast,  and  cephalotribe.  One 
blade  is  spear-pointed,  and  after  serving  as  a  perforator  is  forced  into  the 
base  of  the  skull.     The  second  blade  is  then  introduced  over  the  occiput 


Fig.  406. — Head  Crushed  by  Cranioclast 
(bimpson). 


422 


OBSTETRICS 


and  the  third  over  the  face  of  the  child.  All  three  are  articulated,  and 
the  vise  at  the  handles  is  screwed  down,  with  the  result  that  the  base  of 
the  skull  is  fractured  in  many  directions,  and  the  head  is  compressed  into 


Fig.  407. — Tarxier's  Cephalotribe. 


an  elongated  and  shapeless  mass.    This  is  a  most  efficient  instrument,  and 
has  been  particularly  recommended  by  Pinard  and  Bar. 

J.  E.   Simpson,  of  Edinburgh,  devised  an  instrument  known  as  the 
basilyst,  which  likewise  consists  of  three  blades.     The  tips  of  two-  of  them 


Fig.  408. — Tarnier's  Basiotribe.  Disarticulated. 

come  together  and  form  a  screw-like  instrument.  This  first  perforates  the 
skull,  and  by  a  rotatory  motion  is  then  worked  into  the  base,  which  is 
fractured  in  many  directions  by  separating  the  two  blades  by  pressure  upon 
the  handles.     After  this,  the  third  blade  is  introduced  over  the  face  or 


Fig.  409. — Tarnier's  Basiotribe. 


occiput  and  screwed  tightly  in  place,  thus  converting  the  instrument  into 
a  typical  cranioclast  (Figs.  411  and  412).  The  basilyst  gives  very  satisfac- 
tory results,  and  according  to  its  inventor  will  compress  the  base  of  the  skull 
into  a  mass  3.5  centimetres  in  diameter.    Various  other  instruments  have 


DESTRUCTIVE  OPERATIONS 


423 


been  invented  for  the  same  purpose,  a  full  accomrl  of  \\  hicb  is  bo  be  found 
in  tlic  work  of  Tarnier  and  Budin. 

When  perforating  a  hydrocephalic  child,  it  is  important  to  remember 
thai  the  brain  is  spread  ou1  over  the  interior  of 
the  skull  as  a  Layer  of  tissue  only  a  few  milli- 
metres thick.  When  this  is  perforated,  the 
serum  filling  the  dilated  ventricles  of  the  brain 
escapes  and  the  skull  collapses,  after  which  de- 
livery is  readilv  effected.  Occasionally  perfora- 
tion does  not  result  in  the  death  of  the  child, 
which  promptly  begins  to  cry  after  its  birth. 
In  order  to  guard  against  this  most  distressing 
occurrence,  the  obstetrician  should  not  be  con- 
lent  with  merely  perforating  the  skull  at  one 
point,  but  should  carry  the  instrument  back  to 
the  base  of  the  brain  and  stir  it  around  so  as  to 
effectually  destroy  the  upper  portion  of  the 
medulla.  Especial  care  is  necessary  in  this 
connection  in  order  to  avoid  unpleasant  com- 
plications, Pernice  having  recently  reported  the 
case  of  an  infant  who  survived  craniotomy  and 
grew  up  an  idiot.  And  a  similar  case  has  been 
known  to  occur  in  Baltimore. 

Prognosis^ — In  moderate  degrees  of  pelvic 
contraction,  craniotomy,  if  properly  performed, 
is  almost  devoid  of  danger  to  the  mother.  On 
the  other  hand,  when  the  conjugata  vera  meas- 
ures 5.5  centimetres  or  less,  the  mortality  ex- 
ceeds that  following  Cesarean  section.  It  must 
be  remembered,  however,  that  favourable  re- 
sults are  obtained  only  when  the  mother  is  in 

good  condition;  whereas,  if  the  operation  be  de-     FlG  4io._Effect  of  Basioteibe. 
ferred   until   infection   has   occurred,   it   is    a 

most   serious  procedure,   and  is   attended  by  a  mortality  of   10   to   15 
per  cent. 


Fig.  411. — Simpson's  Basiltst,  Disarticulated 


Embryotomy. — In  embryotomy  the  viscera  are  removed  through  an 
opening  in  the  thorax  or  abdomen  of  the  child,  or  the  head  is  severed  from 


424 


OBSTETRICS 


the  body.     The  former  operation  is  known  as  evisceration,  the  latter  as 
decapitation. 

At  present  evisceration  is  rarely  employed,  though  it  occasionally  he- 
comes  necessary  in  order  to  effect  the  delivery  of  certain  monstrosities  or 


Fig.  412. — Simpson's  Basilyst,  Articulated. 

children  suffering  from  unusual  enlargement  of  the  thoracic  or  abdominal 
cavities,  resulting  from  tumour  formation  or  the  accumulation  of  fluid. 
It  may  likewise  become  necessary  in  rare  cases  of  transverse  presentation, 
when  the  thorax  or  abdomen  of  the  child  lies  over  the  superior  strait  and 
the  neck  is  not  accessible.  Under  such  circumstances  an  opening  is  made 
by  scissors  through  the  thoracic  or  abdominal  wall,  as  the  case  may  be, 
sufficiently  large  to  admit  two  fingers,  with  which  the  viscera  are  then 
torn  loose  from  their  attachments  and  slowly  extracted. 

Decapitation  is  much  more  frequently  employed,  and  is  indicated  more 
particularly  m~  neglected  transverse  presentations.  As  a  rule,  when  seen 
early,  such  cases  can  be  readily  delivered  by  version  and  extraction;  but 
exceptionally  the  condition  is  overlooked,  and  assistance  is  not  called  for 
until  one  shoulder  has  become  firmly  impacted  in  the  pelvic  canal,  the 

lower  uterine  segment  at  the 
same  time  being  so  stretched 
as  to  make  an  attempt  at  ver- 
sion practically  synonymous 
with  rupture  of  the  uterus. 
Under  such  circumstances  the  child  can  be  delivered  only  by  decapitation, 
which  can  readily  be  accomplished  by  means  of  Braun's  blunt  hook. 

Fortunately,  in  neglected  shoulder  presentations,  decapitation  is  often 
materially  facilitated  by  the  prolapse  into  the  vagina  of  one  arm.  This 
having  been  seized  and  brought  through  the  vulva,  firm  traction  should 
be  exerted  upon  it  so  as  to  put  the  neck  on  the  stretch  as  much  as  pos- 
sible. The  index  finger  of  one  hand  is  then  passed  over  the  neck  and  used 
as  a  guide  in  applying  Braun's  hook  as  accurately  as  possible.  When 
in  position,  the  tip  of  the  instrument  is  covered  by  the  finger  so 
as  to  avoid  wounding  the  maternal  soft  parts.  All  being  in  readiness,  strong 
traction  is  now  made  upon  the  handle  of  the  instrument,  which  at  the 
same  time  is  given  a  rotary  movement,  by  which  the  cervical  vertebras 
become  disarticulated,  and  on  continuation  of  the  motion  the  neck  is 


Fig.  413. — Braun's  Blunt  Hook. 


DESTRUCTIVE  OPERATIONS 


-1-5 


readily  severed  from  the  body.  II'  any  resistance  is  offered  by  the  skin, 
it  may  be  cut  with  scissors.  After  decapitation  the  body  is  extracted  by 
traction  upon  the  arm;  or.  if  lliat  be  not 
available,  by  version.  The  head  can  fre- 
quently be  expressed  from  the  uterus  by 
manoeuvres  similar  to  those  employed  for 
the  delivery  of  the  placenta,  but  if  these 
prove  unsuccessful,  a  linger  is  introduced 
into  the  uterus  and  inserted  into  the 
mouth  of  the  child,  after  which,  as  a  rule, 
extraction  is  readily  effected  by  traction 
upon  the  lower  jaw.  If  this  is  not  effect- 
ual, delivery  can  be  accomplished  by 
means  of  a  cephalotribe  or  after  per- 
foration. 

Zweifel  believes  that  decapitation  can 
be  rendered  easier  by  the  use  of  the 
trachelo  rhelcter,  which  consists  essentially 
of  a  double  Braun's  hook.  So  far  as  my 
own  experience  goes,  I  see  no  necessity 
for  the  new  instrument,  as  I  have  always 
been  able  to  effect  decapitation  by  means 
of  Braun's  hook.  Again,  if  the  latter  be 
not  available,  the  operation  can  be  readily 
performed  by  means  of  a  pair  of  long 
curved  scissors,  similar  to  the  embryoto- 
my scissors  of  Hodge;  while  in  cases  of 
necessity  the  head  may  be  severed  from 
the  trunk  by  passing  a  strong  cord  over 
the  neck  and  using  it  as  a  saw.  When 
this  is  employed,  the  vaginal  walls  must  be  protected  by  a  speculum  to 
prevent  them  from  being  cut  through. 

Occasionally,  in  head  presentations,  the  excessive  size  of  the  shoulders 


Fig.  414. — Decapitation  with  Braun's 
Blunt  Hook  (American  Text-Book). 


Fig.  415.  Fig.  416. 

Figs.  415,  416.— Showing  Mode  of  Action  of  Blunt  Hook  (American  Text-Book). 


426  OBSTETRICS 

may  prove  a  serious  obstacle  to  labour.  In  such  cases  deidotomy,  proposed 
by  Von  Herff  and  Strassmann,  renders  excellent  service.  In  this  operation 
a  pair  of  long  curved  scissors  are  introduced  under  the  guidance  of  the 
hand  and  cut  through  the  clavicles  on  either  side,  after  which  the  shoulder 
girdle  collapses  and  delivery  is  readily  effected. 


LITERATURE 

Bar.     Embryotomie  cephalique.     Paris,  1889. 

Baudelocque.     Nouveau  moyen  pour  delivrer  les  femmes   contrefaites   et   en   travail. 

Paris,  1829. 
Braun.     Ueber  das  technische  Verfahren  bei  vernachlassigten  Queriagen,  etc.     Wiener 

med.  Wochenschr.,  1861,  No.  45. 
Von  Herff.     Die  Zertrummerung  des  Schultergiirtels  (Kleideotomie).     Archiv  f.  Gyn., 

1895,  liii,  542-546. 
Pernice.     Ueber  einen  giinstig  verlaufenen  Fall  von  Perforation,  etc.     Centralbl.  f.  Gyn., 

1900,  918-921. 
Pinard.    Le  basiotribe  Tarnier.     Annales  de  Gyn.  et  d'Obst.,  1884,  xxii,  321-341  and 

406-442. 
Du  soi-disant  foeticide  therapeutique.     Annales  de  Gyn.  et  d'Obst.,  1900,  liii,  1-L8. 
Simpson,  A.  R.     Delivery  by  Basilysis.     Scottish  Med.  and  Surg.  Jour.,  1900  (May). 
Simpson,  J.  Y.     Cranioclast.     Med.  News  and  Gaz.,  1860,  vol.  i. 
Strassmann.      Ueber   die   Geburt   der    Sehultern    und   iiber    den    Schlusselbeinschnitt 

(Cleidotomie).     Archiv  f.  Gyn.,  1897,  liii,  135-143. 
Tarnier.    Le  basiotribe.    Acad,  de  med.  de  Paris,  1883,  December  11.     Annales  de  Gyn. 

et  d'Obst.,  1884,  xsi,  74-77. 
Zweifel.     Ueber  die  Dekapitation,  etc.     Centralbl.  f.  Gyn.,  1895,  521-39. 


CHAPTEK  XXIV 
OPERATIVE  PROCEDURES   WHICH  DO  NOT  AIM  AT  DELIVERY 

I  \  this  chapter  will  he  considered  a  number  of  procedures  usually  desig- 
nated as  minor  operations,  which  may  become  necessary  during  pregnancy, 
labour,  or  the  puerperium. 

The  Douche. — We  distinguish  between  vaginal  and  uterine  douches,  ac- 
cording as  a  considerable  quantity  of  fluid  is  injected  into-the  vaginal  canal 
alone  or  directly  into  the  uterine  cavity. 

Vaginal  Douche. — Following  the  introduction  of  antiseptic  methods 
into  surgery,  the  use  of  an  antiseptic,  prophylactic  vaginal  douche  became 
a  routine  part  of  the  conduct  of  labour,  in  the  belief  that  by  its  means  the 
countless  pathogenic  micro-organisms  supposed  to  exist  in  the  vaginal 
secretion  of  pregnant  women  could  be  destroyed,  or  at  least  rendered 
innocuous,  and  the  risk  of  auto-infection  minimized.  Experimental  work, 
however,  has  shown  clearly  that,  with  the  exception  of  the  gonococcus, 
the  vaginal  secretion  during  pregnancy  rarely,  if  ever,  harbours  pyogenic 
bacteria,  and  that  the  prophylactic  vaginal  douche  is  unnecessary.  Fur- 
thermore, clinical  experience  has  demonstrated  that  it  is  not  only  useless 
but  even  directly  harmful,  as  its  routine  employment  is  followed  by  a 
greater  number  of  febrile  cases  during  the  puerperium  than  when  it  is 
omitted.  This  question  will  be  dealt  with  more  fully  in  the  chapter  upon 
puerperal  infection. 

Accordingly,  at  the  present  time  the  vaginal  douche  is  employed  only 
exceptionally  during  pregnancy  and  labour;  as,  for  instance,  when  the 
pregnant  woman  presents  a  profuse  vaginal  discharge  fine  to  gonorrhoea! 
infection.  In  such  cases,  four  litres  ot  a  hot  l-to-10,000  bichloride  solu- 
tion may  be  injected  into  the  vagina  twice  daily  during  the  last  few  weeks 
of  pregnancy,  not  so  much  in  the  hope  of  curing  the  disease  as  of  avoiding 
infection  of  the  child's  eyes  during  labour.  This  is  all  that  can  reasonably 
be  expected,  inasmuch  as  the  gonococci  are  rarely  limited  to  the  vaginal 
mucosa,  but  have  usually  invaded  the  glands  of  the  cervical  canal,  where 
they  are  protected  from  the  action  of  the  antiseptic  fluid. 

Many  authorities  recommend  the  employment  of  a  prophylactic  vagi-- 
nal  douche  if  the  patient  has  been  subjected  to  repeated  examinations  dur-  \ 
ing  labour  by  persons  who  habitually  neglect  ordinary  aseptic  precau-  1 
tions,  and  particularly  if  signs  of  infection  are  present.  Owing  to  the  ' 
impossibility  of  thoroughly  disinfecting  the  vagina  at  the  time  of  labour, 

427 


428  OBSTETRICS 

the  value  of  such  a  procedure  is  questionable;  but  a  douche  consisting  of 
several  litres  of  hot  sterile  salt  solution  can  do  no  harm  in  such  cases. 

After  the  first  week  of  the  puerperium,  the  vaginal  douche  is  frequently 
employed  when  the  lochia  present  an  offensive  odour.  It  need  hardly  be 
said,  however,  that  it  is  of  but  little  value  as  a  disinfectant,  but  merely 
removes  mechanically  the  secretion  collected  in  the  vagina,  and  thus  adds 
materially  to  the  comfort  of  the  patient.  Sterile  salt  solution  or  a  2^-per- 
cent  solution  of  carbolic  acid,  either  alone  or  combined  with  boric  acid  and 
a  little  oil  of  peppermint,  may  be  employed. 

Occasionally,  when  a  puerperal  .infection  _has  become  localized,  and 
has  given  rise  to  induration  lit"  the  base  o±  theltroad  ligament  or  of  Doug- 
lias's  cul-de-sac,  the  application  of  heat  by  means  of  abundant  douches  of 
a  hot  fluid  markedly  alleviates  suffering,  hastens  the  maturation  of  the 
I  abscess,  and  prepares  the  way  for  its  prompt  evacuation. 

Before  giving  a  vaginal  douche,  the  external  genitalia  should  be  care- 
fully cleansed  and  the  patient  placed  upon  a  douche-pan  as  she  lies  in 
bed,  or  brought  to  the  edge  of  the  bed  and  placed  in  the  obstetrical  posi- 
tion with  a  rubber  pad  beneath  her.  A  fountain-syringe,  containing  four 
quarts  and  provided  with  an  appropriately  shaped  glass  nozzle,  previously 

sterilized  by  boiling,  is 
^  x  employed,  and  the  fluid 

allowed  to  run  in  under 
moderate  gravity  pres- 
sure.   For  the  first  ten 

Fig.  417— Glass  Douche  Tube.  days  of  the  puerperium 

rigid  aseptic  precau- 
tions should  be  observed  in  the  use  of  the  douche,  and  its  administration 
should  not  be  intrusted  to  the  nurse,  unless  one  is  assured  of  her  competency. 

Intra-uterine  Douche. — The  intra-uterine  douche  is  not  employed  so 
long  as  the  uterine  cavity  is  occupied  by  the  product  of  conception,  but 
is  frequently  used  immediately  after  labour  and  during  the  puerperium. 

Formerly  it  was  customary  to  give  an  intra-uterine  douche  after  all 
obstetrical  operations.  Such  a  procedure,  however,  is  indicated  only  when 
the  patient  has  exhibited  signs  of  infection  during  labour;  but  after  de- 
livery IrTTfie^e'Ta^eTanintra-uterine  douche  of  several  litres  of  hot  salt 
solution  does  no  harm  and  occasionally  is  productive  of  good. 

The  most  usual  indication  for  its  employment  immediately  after  labour 
is  afforded  by  post-jmrtum.  lia>morrliaqe  clue  to  atony  of  the  uterus.  In  such 
cases  the  administration  of  a  douche  of  4  or  5  litres  of  hot  sterile  salt 
solution  will  usually  lead  to  efficient  and  permanent  contraction,  provided 
that  fragments  of  the  placenta  are  not  retained  in  utero. 

The  intra-uterine  douche  is  also  frequently  employed  during  the  puer- 
perium, especially  in  the  presence  of  infection.  It  has,  however,  been  great- 
ly abused;  for  while  it  must  be  admitted  that  it  is  frequently  a  most  valuable 
therapeutic  agent,  it  is  nevertheless  true  that  it  may  be  directly  harmful. 
For  these  reasons  great  care  should  be  taken  in  the  selection  of  the  cases 
in  which  it  is  employed.  Generally  speaking,  it  is  contra-indicated  in  all 
cases  of  streptococcic  infection,  inasmuch  as  the  necessary  manipulations 


OPERATIVE   PROCEDURES  WHICH   DO   NUT  AIM    AT   DELIVER?     429 

may  give  rise  to  an  extension  of  (lie  process.  On  the  other  hand,  when 
the  symptoms  are  due  to  infection  by  the  so-called  putrefactive  organisms 
associated  with  retention  of  the  Lochia]  discharge,  the  introduction  into 
the  uterus  of  several  litres  of  hot  salt  solution  is  frequently  followed  by  an 
immediate  fall  of  temperature  and  a  permanent  improvement  in  the  con- 
dition of  the  patient.  Usually  a  single  douche  brings  about  the  desired 
result,  though  occasionally  its  daily  repetition  may  be  necessary. 

Sterile  salt  solution  should  lie  employed  for  i nl  ra-ut eri ne  douching,  in- 
stead  of"the  antiseptic  solutions  which  are  usually  recommended,  since  the 
Latter,  no  matter  how  strong  they  may  be  made,  can  act  only  in  a  purely 
mechanical  way,  and  cannot  destroy  the  bacteria  which  have  already  in- 
vaded the  endometrium.  On  the  other  hand,  their  use  occasionally  causes 
the  death  of  the  patient,  particularly  when  bichloride  of  mercury  is  em- 
ployed. On  looking  over  the  literature  upon  the  subject  several  years 
ago,  I  collected  over  40  cases  in  which  death  from  mercurial  poisoning  fol- 
lowed the  use  of  such  solutions  for  intra-uterine  injection. 

Inasmuch  as  the  administration  of  an  intra-uterine  douche  must  always 
be  regarded  as  a  serious  matter,  it  should  be  given  by  the  physician  him- 
self and  not  delegated  to  the  nurse,  no  matter  how  competent  she  may 
be;  since  the  most  rigid  aseptic  precautions  are  necessary,  and  failure  in 
this  regard  may  result  in  infection  of  the  patient.  As  a  preliminary,  the 
vagina  should  be  douched  out.  Two  fingers  having  then  been  employed  to 
locate  the  external  os,  the  douche-tube  is  passed  through  it  until  it  im- 
pinges upon  the  fundus  of  the  uterus.  Four  or  five  litres  of  fluid  are  then 
slowly  injected,  care  being  taken  to  insure  a  free  return  flow. 

During  the  puerperium  the  cervical  canal  rapidly  diminishes  in  calibre, 
and,  owing  to  the  marked  anteflexion  of  the  uterus  which  frequently  occurs 
in  this  period,  may  become  so  bent  as  to  offer  a  considerable  obstacle  to 
the  introduction  of  the  nozzle.  To  overcome  this  difficulty,  traction  is  made 
upon  the  anterior  lip  of  the  cervix  by  means  of  a  pair  of  bullet  forceps, 
as  a  result  of  which  the  cervical  canal  becomes  straightened  out  so  that 
the  nozzle  can  readily  be  introduced.  Occasionally,  the  contraction  ring 
offers  an  obstacle,  and  the  nozzle  is  arrested  in  the  collapsed  lower  uterine 
segment.  By  making  traction  upon  the  cervix,  and  cautiously  moving  the 
extremity  of  the  douche-tube,  it  can  usually  be  passed  into  the  uterine] 
cavity  without  further  difficulty. 

Curettage.— By  this  term  is  understood  the  removal  of  the  lining  mem- 
brane of  the  uterus  by  means  of  a  curette.    The  operation  may  be  indicated  J 
in  three  conditions:  incomplete  abortion,  imperfecf  involution  ot  the  miex- 
peral  uterus,  and  certain  cases  ot  infection.  / 


5*€ 


Fig.  418. — Curette. 


When  portions  of  the  placenta  and  membranes  are  retained  within  the 
uterus  after  an  incomplete  abortion,  many  authorities  recommend  their 
removal  by  means  of  a  dull  curette.    As  a  preliminary,  the  cervix,  if  not  suf- 


430  OBSTETRICS 

ficiently  pervious,  must  be  dilated  by  a  suitable  instrument,  preferably  one 
modelled  after  that  of  Goodell  (see  Fig.  319).  The  curette  is  then  intro- 
duced into  the  uterus  and  gently  scrapes  off  the  retained  structures.  The 
employment  of  an  instrument,  however,  is  rarely  advisable,  as  it  is  far 
better  to  peel  off  the  adherent  placenta  and  membranes  with  one  or  two 
fingers,  while  the  other  hand  controls  their  movements  through  the 
abdominal  walls.  After  they  are  once  loosened,  the  retained  structures 
can  be  readily  removed  by  means  of  the  fingers  or  an  ovum  or  pla- 
cental forceps.  The  former  procedure  necessitates  the  introduction  of 
the  entire  hand  into  the  vagina,  and  can  only  be  accomplished  under 
anaesthesia. 

After  the  uterus  has  been  emptied  in  such  cases,  the  fingers  are  again 
introduced  and  carefully  palpate  its  cavity,  in  order  to  make  sure  that  the 
offending  structures  have  been  entirely  removed  and  all  danger  of  subse- 
quent haemorrhage  has  been  averted.  If  the  curette  is  used,  considerable 
portions  of  placenta  may  be  left  behind,  which  may  later  give  rise  to  bleed- 
ing and  necessitate  another  operation.  On  several  occasions  I  have  seen 
cases  in  consultation  in  which  haemorrhage  had  persisted  after  curettage, 
and  on  examination  found  that  considerable  portions  of  the  placenta,  or 
even  the  entire  structure,  had  been  left  in  the  uterus,  the  physician  having 
removed  only  a  part  of  the  decidua  at  the  previous  operation.  Moreover, 
curettage  always  carries  with  it  the  possibility  of  perforating  the  uterus, 
the  walls  in  many  cases  being  so  soft  and  friable  that  the  accident  may 
occur  despite  the  exercise  of  the  utmost  caution.  Fortunately,  the  injury 
in  generally  attended  by  but  little  danger,  although,  if  the  uterine  contents 
be  infected,  it  may  give  rise  to  fatal  peritonitis;  again,  in  rare  cases,  a  loop 
of  gut  may  prolapse  through  the  rent  in  the  uterus  and  necessitate  a  major 
i  operation. 

Probably  the  most  justifiable  indication  for  curettage  in  obstetrical 
practice  is  the  loss  of  blood  during  the  latter  part  of  the  puerperium,  re- 
sulting from  imperfect  involution  of  the  uterus,  which  is  frequently  asso- 
ciated with  the  reteniion_ofj20j^i£nj^^  Tinder 
such  circumstances  the  bperatidngives^cellent  results,  provided  it  be  car- 
ried out  in  an  aseptic  manner. 

Most  authorities  recommend  curettage  in  puerperal  infection,  in  the  be- 
lief that  by  its  means  the  focus  of  infection  can  be  removed.  The  opera- 
tion is  undoubtedly  beneficial  in  a  certain  number  of  cases,  but  should  be 
instituted  only  in  the  presence  of  definite  indications,  as  the  routine  em- 
ployment of  the  curette  is  frequently  more  dangerous  than  the  original 
infection,  and  has  led  to  the  death  of  many  hundreds  of  women.  Generally 
speaking,  it  is  contra-indicated  when  the  infection  is  due  to  the  strepto^ 
coccus,  as  under  such  circumstances  the  lesions  attending  its  use  simply 
offer  new  areas  for  infection.  On  the  other  hand,  it  is  often  followed  by 
excellent  results  wben  the  so-called  putrefactive  organisms  are  producing 
the  mischief,  and  the  uterine  cavity  contains  necrotic  tissue  and  occasion- 
ally larger  or  smaller  portions  of  degenerated  placenta.  Nevertheless,  in 
this  class  of  cases  it  is  generally  far  better  to  employ  the  fingers  in  emptying 
the  uterus. 


OPERATIVE    I'RocKDl'KES   WIIKll    Do    NOT    AIM    AT    DELIVERY     4:11 


The  Tampon  or  Pack. — The  «aginal  tampon  i<  occasionally  indicated 
in  the  following  conditions:  ineviiahle  ahortion.  certain  cases  of  placenta 
praevia,  and  to  dilate  i he  cervi.v  in  the  early  months  of  pregnancy.  Profuse 
haemorrhage  occurring  in  the  early  months  of  pregnancy  usually  indicates 
that  iilmrliiiiL  is  inevitable.  In  such  cases,  if  the  cervical  canal  i-  not 
sufficiently  dilated  to  admit  the  finger,  it  is  often  advisable  to  pack  it 
and  the  vagina  tightly  with  sterile  gauze  and  adniinister  ergot.  When 
the  packing  is  removed  twelve  or  twenty-four  hours  Later,  the  product  of 
conception  is  frequently  found  Lying  free  in  the  vaginal  vault,  and  when 
this  (hies  not  oeeui'  the  cervical  canal  will  usually  be  sufficiently  dilated 
to  permit  the  introduction 
of  the  finger,  by  means  of 
which  the  uterus  can  be 
emptied. 

In  /Jgrrxhi  pr  curia 
when  the  haemorrhage  is 
alarming  and  the  cervical 
canal  is  not  sufficiently  di- 
lated to  admit  a  finger,  ex- 
cellent results  occasionally 
follow  the  application  of  a 
tight  tampon  to  the  cer- 
vical canal  and  vagina. 
This  effectually  controls 
haemorrhage,  and  on  its 
removal  a  few  hours  later 
the  cervix  will  usually  he 
sufficiently  dilated  to  admit 
two  fingers,  after  which 
combined  version  by  the 
Braxton  Hicks  method  can 
he  performed,  or  manual 
dilatation  effected,  fol- 
lowed by  the  immediate  ex- 
traction of  the  child. 

In  the  early  months  of 
pregnancy  a  tightly  applied 
pack  offers  an  excellent 
means  of  dilating  the  cervix 
in  any  condition  which  de- 
mands the  evacuation  of 
the  uterine  contents,  and 
in  many  cases  is  preferable 
to  rapid  instrumental  dilatation.  This  is  particularly  true  in  hvdatidiform 
mole  and  in  certain  cases  of  so-called  missed  abortion. 

The  best  material  for  d  vaginal  tampon  is  gauze,  which  is  most  con- 
veniently handled  in  the  shape  of  roller-gauze  bandages,  3  or  4  inches 
wide,  which  have  previously  been   carefully  sterilized.     For  the   intro- 


Fig.  419. 


-Packing  the   Utekus  foe  Post-pabtbii 

hemorrhage. 


432  OBSTETRICS 

duction  of  the  pack  the  patient  should  be  brought  to  the  edge  of  the  bed 
and  subjected  to  the  usual  preparations  for  an  operation.  A  bivalve,  or 
preferably  a  Simon  speculum,  is  then  introduced  into  the  vagina  and  the 
cervix  seized  with  a  bullet  forceps.  Then  with  a  long  dressing  forceps  the 
bandage  is  carried  up  and  tightly  packed  into  the  cervical  canal,  and  after- 
ward into  the  fornix,  so  that  eventually  the  entire  vagina  is  completely 
filled  with  it  (see  Fig.  323). 

Intra-uterine  Pad: — Diihrssen,  in  1887,  advocated  packing  the  uterus 
with  iodoform  gauze  as  a  means  of  controlling  haemorrhage.  Whenever 
there  is  persistent  loss  of  blood  following  the  third  stage  of  labour,  which 
does  not  yield  to  the  ordinary  methods  of  treatment,  this  procedure  offers  a 
most  efficient  method  of  controlling  it,  as  the  pack  not  only  exerts  pressure 
upon  the  bleeding  vessels  but  mechanically  stimulates  the  uterus  to  re- 
newed contraction.  Plain  sterilized  gauze  may  be  substituted  for  that  im- 
pregnated with  iodoform  or  other  antiseptics. 

Before  resorting  to  this  procedure,  however,  it  is  essential  .that  the 
hand  be  introduced  into  the  uterus  in  order  to  ascertain  that  the  haemor- 
rhage is  not  due  to  retention  of  portions  of  the  placenta.  If  the  uterus  is 
empty,  after  the  usual  preparations  for  an  operation  have  been  carried  out, 
the  anterior  lip  of  the  cervix  is  seized  with  a  bullet  forceps  and  drawn 
down  as  near  as  possible  to  the  vulva,  after  which  sterilized  bandages  are 
rapidly  packed  into  the  uterine  cavity  by  means  of  a  long  dressing  forceps, 
the  upper  part  of  the  vagina  being  also  tamponed  (Fig.  419).  The  pack 
should  be  allowed  to  remain  in  place  for  twenty-four  hours,  after  which  it 
can  be  removed  by  traction  upon  its  free  end. 

Manual  Removal  of  the  Placenta. — When  considering  the  treatment  of 
the  third  stage  of  labour,  it  was  pointed  out  that  previous  to  the  intro- 
duction of  Creole's  method  of  expressing  the  placenta  its  manual  removal 
was  frequently  resorted  to.  With  increasing  knowledge  as  to  the  proper 
conduct  at  this  time,  however,  the  operation  became  less  and  less  fre- 
quently demanded,  so  that  at  present  competent  obstetricians  consider 
that  it  is  indicated  only  about  once  in  several  hundred  cases,  and  then 
only  when  abnormal  adhesions  exist  between  the  placenta  and  the  ute- 
rine wall,  or  when  one  has  to  do  with  a  placenta  membranacea  or  suc- 
centuriata. 

Manual  removal  is  indicated  whenever  there  is  alarming_Jiaemorrhage 
and  the  placenta  cannot  be  expressed  by  Crede's  method,  though  such  a 
condition  is  but  rarely  observed.  On  the  other  hand,  if  there  is  no  haemor- 
rhage, the  operation  should  not  be  resorted  to  merely  to  hasten  the  comple- 
tion of  the  third  stage  of  labour.  Generally  speaking,  in  such  cases,  repeat- 
ed attempts  at  expression  by  Crede's  manoeuvre  should  be  persisted  in  for 
at  least  an  hour,  under  anaesthesia,  if  necessary,  and  manual  removal  resorted 
to  only  after  prolonged  effort  has  shown  that  more  conservative  methods  are 
ineffectual.  The  procedure  is  attended  by  grave  danger,  and  offers  a  greater 
opportunity  for  infection  than  any  other  obstetrical  manipulation.  In  the 
ordinary  operations,  such  as  forceps  and  version,  the  hand,  when  introduced 
into  the  uterus,  is  within  the  amniotic  cavity,  and  consequently  micro-organ- 
isms which  may  have  been  introduced  along  with  it,  are  cast  off  when  the 


OPKKATIVK    I'UOCKDURKS    WHICH    DO   NOT    AIM    AT    DELIVERY    433 

after-birth  is  expelled;  whereas,  in  manual  removal  of  the  placenta  the  hand 
is  inserted  betweer  the  foetal  membranes  and  the  uterine  wall,  and,  in  sepa- 
rating the  placenta  from  its  attachments,  comes  in  direct  contact  with  the 
gaping  or  thrombosed  sinuses,  so  that  if  it  be  not  absolutely  sterile  abundant 
facilities  for  infection  arc  offered. 


Fig.  420. — Manual  Kemoval  of  Placenta. 


When  the  operation  becomes  necessary,  the  strictest  attention  should, 
be  given  to  every  aseptic  detail.  The  external  genitalia  should  be  most 
rigorously  cleansed,  the  hands  and  forearms  of  the  operator  carefully  dis- 
infected, and  rubber  gloves  employed.  After  grasping  the  uterus  through 
the  abdominal  wall  with  one  hand,  the  other,  lubricated  with  sterile  vase- 
line, is  introduced  into  the  vagina  and  passed  into  the  uterus,  following  the 
umbilical  cord.  As  soon  as  the  placenta  is  reached  its  margin  should  be 
sought  for  and  the  inner  surface  of  the  hand  insinuated  between  it  and  the 
uterine  wall.  Then,  with  the  back  of  the  hand  in  contact  with  the  latter, 
the  placenta  should  be  peeled  off  from  its  attachment  by  a  motion  similar 
to  that  employed  in  cutting  the  leaves  of  a  book.  After  its  complete  separa- 
tion, the  placenta  should  be  grasped  in  the  entire  hand,  but  not  extracted 
immediately,  the  operator  waiting  until  the  uterus  contracts  down  firmly 
over  the  hand,  which  should  then  gradually  be  withdrawn. 

Once  again  the  importance  of  a  most  rigid  aseptic  technique  in  carrying 
out  this  procedure  must  be  emphasized.     Naturally,  when  the  obstetrician 


434  OBSTETRICS 

finds  himself  face  to  face  with  an  alarming  post-partum  hemorrhage,  his 
only  thought  is  likely  to  be  as  to  the  most  rapid  method  of  checking  it, 
without  regard  to  details.  But  even  in  such  cases,  the  hand  should  be  care- 
fully redisinfected,  or  at  least  encased  in  a  sterile  rubber  glove,  for  if  it 
be  introduced  into  the  uterus  without  proper  precautions,  the  patient,  al- 
though saved  from  death  from  haemorrhage,  may  succumb  to  a  virulent 
infection  a  few  days  later. 


PATHOLOGY    OF    PREGNANCY 

CHAPTER  XXV 
ACCIDENTAL    COMPLICATIONS   OF  PREGNANCY  DUE    TO    DISEASE 

Pregnancy  may  be  associated  with  certain  diseases  which  result  from 
the  condition  itself,  or  by  others  which  are  to  be  regarded  as  accidental 
complications.  The  latter  may  have  existed  before  the  inception  of  preg- 
nancy, or  may  have  been  acquired  during  its  course. 

As  a  rule,  all  diseases  which  subject  the  organism  to  a  considerable 
strain  are  much  more  serious  when  occurring  in  the  pregnant  woman. 
Thus,  a  lung  which  is  partially  destroyed  or  thrown  out  of  function  may 
suffice  for  the  respiration  of  an  ordinary  individual,  but  be  unable  to 
respond  to  the  added  demands  of  pregnancy,  particularly  in  the  latter 
months,  when  the  enlarged  uterus  restricts  the  mobility  of  the  diaphragm. 
Similarly,  many  a  woman  is  unaware  of  the  existence  of  a  cardiac  lesion, 
or  at  least  leads  a  very  comfortable  existence,  until  the  increased  demands 
upon  the  activity  of  the  heart  incident  to  pregnancy  bring  about  broken 
compensation  with  its  attendant  symptoms. 

In  general,  it  may  be  said  that  pregnancy  exerts  a  deleterious  influence 
upon  all  chronic  organic  maladies,  while  its  effect  is  usually  less  marked  in 
acute  infectious  processes.  The  latter,  however,  frequently  lead  to  pre- 
mature delivery,  and  the  additional  physical  strain  attending  the  latter  may 
render  the  course  of  the  disease  much  less  favourable. 

Pregnancy  complicated  by  Acute  Infectious  Diseases. — Small-pox. — 
8mall-pox  complicating  pregnancy  carries  with  it  a  more  serious  prognosis 
than  at  other  times.  Thus  Tinay  reported  a  mortality  of  36  per  cent  in 
"235  cases,  as  compared  with  25  per  cent  in  the  non-pregnant  condition. 
The  hemorrhagic  form  of  the  disease  is  particularly  fatal  in  pregnant 
women,  Mayer  having  recorded  the  loss  of  13  consecutive  cases. 

Moreover,  small-pox  exerts  a  deleterious  influence  upon  the  product  of 
conception,  and  frequently  causes  abortion  or  premature  labour.  This 
may  be  due  to  hemorrhagic  clianges  in  Lhe^decidua,  or  to  the  direct  trans- 
mission of  the  disease  to  the  foetus,  with  its  subsequent  death  and  expulsion. 
The  occurrence  of  intra-uterine  small-pox  is  well  authenticated,  as  children 
are  occasionally  born  in  the  eruptive  stage  of  the  disease  or  with  distinct  | 
pock-marks.  Mauriceau  is  said  to  have  been  infected  in  this  manner,  and 
the  condition  was  well  known  to  John  Hunter  and  Smellie.  Cordes  re- 
ported a  similar  case  in  1900. 

29  435 


436  OBSTETRICS 

Bollinger  first  suggested  the  possibility  of  the  transmission  from  mother 
to  foetus  of  the  protective  influence  of  vaccinia,  and  stated  that  when 
the  mothers  are  successfully  vaccinated  during  pregnancy  a  certain  number 
of  the  children  fail  to  take  when  vaccinated  soon  after  birth.  Behm  noted 
this  insusceptibility  once  in  29  cases,  and  believed  that  it  was  due  to  the 
transmission  of  an  immunizing  substance  through  the  placenta.  Kolloch 
held  similar  views.  On  the  other  hand,  most  authorities  are  sceptical  as 
to  the  possibility  of  such  an  occurrence,  and  consider  that  unsuccessful 
vaccination  in  young  children  indicates  that  they  are  refractory  to  its 
influence,  or  that  the  virus  was  of  poor  quality.  In  46  cases  reported  by 
Wolff,  Palm,  and  Gast  there  was  not  a  single  instance  of  successful  intra- 
uterine transmission. 

Scarlet  Fever. — It  is  generally  believed  that  the  pregnant  woman  pos- 
sesses a  certain  immunity  to  scarlet  fever.  Braxton  Hicks  and  others  con- 
sidered that  this  was  demonstrated  by  the  fact  that  the  disease  occurs 
much  less  frequently  during  pregnancy  than  in  the  puerperium.  Ols- 
hausen,  who  also  held  this  view,  was  able  to  collect  from  the  literature 
only  7  cases  of  scarlet  fever  occurring  in  the  former,  as  compared  with 
134  in  the  latter  period.  It  is  quite  possible,  however,  that  many  of  the 
puerperal  cases  were  not  examples  of  true  scarlet  fever,  confusion  having 
arisen  on  account  of  the  rash  which  sometimes  occurs  in  puerperal  infec- 
tion. The  correctness  of  this  latter  supposition  is  supported  by  the  fact 
that  many  authors  believe  in  the  intercommunicability  of  the  two  diseases, 
a  point  that  cannot  be  demonstrated  until  the  materies  morbi  of  scarlet 
fever  has  been  discovered. 

When  occurring  in  the  early  months  of  pregnancy  the  disease  frequently 
[causes  abortion.  This  accident  is  usually  attributed  to  the  high  tem- 
Jperature  of  the  mother,  though  in  very  rare  instances  it  may  be  due  to 
the  direct  transmission  of  the  disease  to  the  foetus,  Ballantyne  having  re- 
corded a  case  in  which  the  child  presented  a  characteristic  rash  at  birth. 
This  view,  however,  has  never  met  with  any  general  acceptation. 

Measles. — Measles  is  not  a  frequent  complication  of  pregnancy,  but 
when  it  occurs  is  very  prone  to  cause  premature  delivery,  which  was  ob- 
served by  Klotz  in  9  out  of  11  cases.  It  is  stated  tnatrmtTa-uterine  trans- 
mission of  the  disease  to  the  foetus  is  now  and  again  noted,  Lomer,  Fiori, 
and  others  having  reported  cases  in  which  the  child  presented  a  character- 
istic eruption  at  birth. 

Cholera. — Pregnant  women  do  not  appear  to  be  attacked  by  cholera  more 
frequently  than  others,  although  they  succumb  more  readily  to  the  disease. 
Sehiitz  states  that  the  mortality  among  them  in  the  Hamburg  epidemic 
of  1892  was  57  per  cent. 

The  disease  exerts  a  very  deleterious  effect  upon  pregnancy,  54  per 
cent  of  the  cases,  according  to  Sehiitz,  ending  in  abortion  or  premature 
labour.  This  may  be  due  to  various  causes.  One  third  of  the  women  suf- 
fering from  cholera  have  more  or  less  profuse  uterine  haemorrhage,  which 
when  occurring  during  pregnancy  gives  rise  to  serious  changes  in  the 
decidua,  Slavjansky  having  described  a  peculiar  form  of  hsemorrhagic  endo- 
metritis in  such  cases.     Moreover,  in  nearly  every  instance,  the  disease 


ACCIDENTAL   COMPLICATIONS  OF   PREGNANCY    DUE  TO   DISEASE    4:;, 

causes  uterine  contractions,  which  arc  supposed  to  result  from  the  cir- 
culation of  toxines  in  the  l»l I. 

Most  authorities  'I t  believe  in  the  direct  transmission  of  cholera 

bacilli  to  the  child,  Tizzoni  and  Cantani  being  the  only  investigators  who 
have  demonstrated  it  for  human  beings.    On  the  other  hand.  Vitanza's 
periments  render  it  probable  that  such  an  occurrence  is  quite  frequent  in 
animals. 

Typhoid  Fever. — Typhoid  fever  i-  a  sja^ous,  and  often^ dangerous  com- 
plication  of  pregnancy.  Moreover,  i1  increases*  largely  the  foetal  mortality, 
abortion,  or  prematuf 6"labour  occurring  in  two  thirds  of  the  cases.  Usually 
the  death  of  the  foetus  and  its  subsequent  expulsion  are  due  to  the  high 
temperature  characterizing  the  disease,  or  to  the  transmission  of  toxines 
through  the  placenta.  In  a  smaller  number  of  cases,  however,  the  bacilli 
themselves  pass  into  the  foetal  circulation.  Thus,  in  my  own  clinic,  F.  W. 
Lynch  was  able  to  demonstrate  them  in  the  organs  of  a  foetus  aborted  by 
a  woman  suffering  from  typhoid  fever  at  the  Johns  Hopkins  Hospital,  and 
similar  cases  have  been  reported  by  Lubarsch,  Speier,  and  others. 

Pneumonia. — The  maternal  mortality  is  materially  augmented  when 
pneumonia  occurs  during  pregnancy,  since  the  disease  frequently  leads  to 
premature  labour  or  abortion.  This  result  is  usually  due  to  imperfect  oxy- 
genation of  the  fcetal  blood,  though  in  a  small  number  of  cases  it  is  attribu- 
table to  the  direct  transmission  of  bacteria  to  the  foetus,  in  whose  organs 
pneumococci  have  been  demonstrated  by  Levy,  Xetter,  Carbonelli,  Lu- 
barsch, and  others. 

Premature  labour  is  a  very  untoward  complication  in  such  cases,  as  the 
exertion  incident  to  it  subjects  the  already  weakened  maternal  organism 
to  so  great  an  additional  strain  that  death  frequently  results. 

Influenza. — According  to  many  authorities,  influenza  exerts  a  very  per- 
nicious influence  upon  pregnancy,  Felkin  and  Muller  having  observed  pre- 
mature labour  in  6  out  of  7,  and  in  15  out  of  21  cases  respectively.  In  most 
of  these  cases  the  interruption  of  pregnancy  was  preceded  by  profuse  metror- 
rhagia, which  was  supposed  to  be  directly  connected  with  the  disease.  On 
the  other  hand.  Bar  and  Boulle.  and  Ahlfeld  state  that  the  disease  is  almost 
without  influence  upon  gestation,  the  first-named  observers  having  noted 
premature  delivery  only  twice  in  -41  cases.  It  would  appear,  therefore,  that 
the  effects  of  influenza  must  vary  with  the  severity  of  the  epidemic,  and 
more  particularly  with  the  frequency  of  pneumonic  complications. 

Erysipelas  and  Sepsis. — Erysipelas  is  a  very  serious  disease  at  any  time, 
but  is  particularly  dangerous  when  occurring  in  pregnant  women,  in  whom 
the  possibility  of  a  streptococcic  puerperal  infection  is  markedly  increased. 
Occasionally,  as  noted  by  Lebedeff.  the  streptococci  which  have  given  rise 
to  the  erysipelas  may  be  transmitted  from  mother  to  child,  though  this  is 
unusual. 

Furthermore,  as  a  rule,  any  septic  condition  offers  a  worse  prognosis  in 
pregnancy  than  at  other  times.  Kronig  has  reported  several  instances  of 
transmission  of  the  offending  bacteria  to  the  child.  In  one  case  he  found 
that  colon  bacilli  had  been  transmitted  from  a  parametritic  abscess  to  the 
foetus,  and  could  be  demonstrated  in  its  tissues.    He  made  similar  observa- 


438  OBSTETRICS 

tions  in  an  infectious  process  due  to  an  anaerobic  bacillus,  as  well  as  in  sev- 
eral cases  of  streptococcic  infection. 

Gonorrhoea. — The  occurrence  of  gonorrhoea  in  the  pregnant  woman 
should  never  be  lightly  regarded.  In  not  a  few  instances  the  organisms  in- 
vade the  decidua  and  give  rise  to  inflammatory  conditions  which  lead  to 
abortlom  Gonococci  have  been  demonstrated  in  decidual  endometritis  by 
Neumann,  Maslovsky,  myself,  and  others. 

More  important,  however,  are  the  consequences  of  gonorrhoea!  infec- 
tion at  the  time  of  labour  and  during  the  puerperium,  leaving  out  of  con- 
sideration, for  the  present,  the  frequency  of  ophthalmia__neonatorum,  to 
which  reference  has  already  been  made.  After  labour  the  gonococci,  which 
have  remained  limited  to  the  cervical  canal  during  pregnancy,  may  gain 
access  to  the  uterine  cavity  and  give  rise  to  febrile  phenomena.  The  con- 
dition, although  rarely  fatal,  is  always  serious,  since  it  frequently  leads 
to  involvement  of  the  uterine  appendages,  which  may  render  the  patient 
permanently  sterile,  or  even  necessitate  operative  measures  at  a  later  date. 
In  rare  instances  the  gonococcus  may  produce  a  general  infection,  Dabney 
and  Harris  having  reported  a  case  of  gonorrhceal  endocarditis  which  was 
observed  in  a  woman  delivered  at  the  Johns  Hopkins  Hospital. 

Tetanus. — Always  a  very  dangerous  disease,  tetanus  is  fortunately  a 
rare  complication  of  pregnancy,  nor  does  it  appear  to  be  more  fatal  than  in 
non-pregnant  women.  Archambaud  has  recently  reported  a  case  which  ter- 
minated favourably. 

Anthrax. — Anthrax,  or  malignant  pustule,  is  rarely  observed  in  human 
beings  under  any  circumstances,  but  is  almost  always  fatal.  EostoAYzen 
met  with  three  deaths  in  pregnant  women,  and  was  able  in  each  case  to 
demonstrate  anthrax  bacilli  in  the  tissues  of  the  child.  A  similar  observa- 
tion was  made  by  Paltauf.  Ahlfeld  and  Marchand  have  reported  a  case 
in  which  a  child,  born  of  a  mother  suffering  from  anthrax,  died  a  few  days 
after  birth  from  the  same  disease.  It  remained  doubtful,  however,  whether 
the  case  was  one  of  intra-uterine  transmission  or  of  post-natal  infection.  In 
certain  animals,  on  the  other  hand,  the  placental  transmission  of  anthrax 
can  frequently  be  demonstrated  experimentally.  The  first  observations  of 
this  character  were  made  by  Strauss  and  Chamberlent  in  1882. 

Pregnancy  complicated  by  Chronic  Infectious  Diseases. — Tuberculosis. — 
Formerly  it  was  believed  that  pregnancy  exerted  a  beneficial  effect  upon 
tuberculosis,  the  mother  improving  markedly  as  long  as  she  carried  the 
child,  though  she  frequently  succumbed  rapidly  after  its  birth.  At  present, 
however,  it  is  generally  conceded  that  its  effect  is  almost  always  harmful. 
Moreover,  the  strain  incidental  to  labour  and  the  extra  drain  upon  the 
system,  if  the  mother  nurses  the  child,  pull  such  patients  down  still  further, 
so  that  the  final  result  is  usually  hastened. 

On  the  other  hand,  the  disease  does  not  appear  to  predispose  to  pre- 
mature^jnterruption^of  pregnancy,  andit  is~not  uniisttal  for  tuberculous~pa- 
tients  to  give  birth  to  large  ami  splendidly  developed  children  at  full  term. 

In  very  exceptional  cases  tuberculosis  may  be  transmitted  from  mother 
to  child.  Hauser  (1898)  collected  from  the  literature  18  cases  in  which 
the  transmission  of  tubercle  bacilli  was  definitely  demonstrated.     In  9  of 


ACCIDENTAL -COM PLICATIONS   OF    PREGNANCY    DUB   To   DISEASE    439 

these  the  children  were  distinctly  tuberculous  at  birth,  in  5  tubercle  bacilli 
were  found  in  the  various  organs,  but  specific  foci  were  not  present,  while 
in  1  cases  tuberculous  lesions  could  be  demonstrated  in  the  foetal  portion 
of  the  placenta.  Later  Auche  and  ( 'hainherlent  discovered  distinct  evi- 
dences of  tuberculosis  in  a  child  twenty-six  days  old,  and  considered  that 
the  disease  was  congenital.  Full  literature  upon  this  subject  is  contained 
in  the  article  of  Diirck  and  Oberndorfer. 

When  one  considers,  however,  the  large  number  of  tuberculous  women 
who  become  pregnant,  and  the  very  small  proportion  of  cases  in  which  the 
transmission  of  the  disease  to  the  foetus  has  been  demonstrated,  it  is  ap- 
parent that  the  latter  must  be  a  very  exceptional  occurrence.  Presumptive 
evidence  in  favour  of  this  view  was  supplied  by  a  case  occurring  at  the  Johns 
Hopkins  Hospital.  The  mother  had  died  from  a  tuberculous  peritonitis  a 
short  time  after  delivery,  and  at  the  autopsy  the  exterior  of  the  uterus 
was  found  studded  with  tubercles,  while  the  interior  was  covered  with 
tuberculous  ulcers  and  caseous  material.  The  condition  was  suspected  at 
the  time  of  labour,  and  with  a  view  of  determining  whether  the  placenta 
contained  tubercle  bacilli  guinea-pigs  were  inoculated  with  portions  of  it, 
but  with  negative  results.  Cultures  taken  from  the  interior  of  the  uterus 
during  life  revealed  the  presence  of  tubercle  bacilli.  The  child,  however, 
presented  no  signs  of  the  disease,  and  was  perfectly  well  some  months  later. 

It  would  appear,  therefore,  that  in  the  vast  majority  of  cases  the  dis- 
ease is  not  transmitted  directly  from  the  mother  to  the  foetus,  and  that 
Baumgartner  and  Alaffucci  are  correct  in  holding  that  the  child  is  born  with 
a  tendency  to  the  disease  rather  than  with  the  disease  itself.  Hence  it 
follows  that  the  children  of  tuberculous  mothers  should  be  brought  up 
under  the  best  hygienic  surroundings,  and  should  not  be  nursed  by  their 
mothers.  Various  authorities  have  recommended  the  induction  of  pre- 
mature labour  in  women  suffering  from  advanced  tuberculosis.  This, 
however,  is  justifiable  only  in  the  interests  of  the  child,  in  the  rare  cases 
in  which  the  woman  is  so  ill  that  it  does  not  seem  probable  that  she  will  live 
until  the  end  of  pregnancy. 

Malaria. — Despite  the  somewhat  widespread  opinion  to  the  contrary, 
it  would  appear  that  the  ordinary  forms  of  malaria  have  but  little  influence 
upon  the  course  of  pregnancy,  although  Goth  has  reported  that  19  out 
of  46  cases  ended  in  premature  labour,  and  Edmonds  states  that  this  acci- 
dent is  very  common  in  Africa. 

I  have  observed  15  cases  of  malaria  complicating  pregnancy,  the  diag- 
nosis being  assured  by  the  demonstration  of  the  characteristic  plasmodium. 
The  character  of  the  infection  was  as  follows: 

Tertian 1  ease. 

Double  tertian 4  cases. 

Triple  tertian 1  case. 

iEstivo-autumnal 6  cases. 

Character  of  organism  not  recorded 3  rases. 

Xone  of  these  patients  aborted,  and  in  but  two  did  pregnancy  end  pre- 
maturely, and  then  only  a  week  or  so  before  term.     It  is  probable,  how- 


440  OBSTETRICS 

ever,  that  the  pernicious  forms  of  malaria  may  have  a  much  more  deleteri- 
ous effect.  There  is  a  marked  tendency  towards  recrudescence  of  the  dis- 
ease during  pregnancy  and  the  puerperium,  just  as  is  frequently  observed 
after  surgical  operations. 

It  is  generally  stated  that  the  disease  is  frequently  transmitted  to  the 
foetus,  Eunge  believing  that  conclusive  evidence  of  such  an  occurrence  is 
afforded  by  the  presence  of  characteristic  pigmentation  in  its  organs,  while 
Kolloch  says  that  it  is  not  unusual  for  the  new-born  child  to  have  charac- 
teristic malarial  attacks.  In  a  number  of  our  cases  the  patients  were  suffer- 
ing from  malaria  at  the  time  of  labour,  but  in  no  instance  did  the  foetus 
present  signs  of  the  disease,  though  in  all  such  cases  its  blood  was  carefully 
and  repeatedly  examined  for  malarial  parasites. 

Quinine  should  be  administered  unhesitatingly  to  women  suffering  from 
malaria  during  pregnancy,  as  its  oxytoxic  properties  are  apparently  in 
abeyance  under  such  conditions,  so  that  it  can  be  used  with  impunity  with- 
out fear  of  setting  up  uterine  contractions. 

Syphilis. — Syphilis  is  one  of  the  most  important  complications  of  preg- 
nancy, as  it  is  one  of  the  most  frequent  causes  of  abortion  or  premature 
labour.  It  should  be  suspected  in  all  cases  in  which  a  perfectly  satisfactory 
explanation  for  this  accident  cannot  be  adduced. 

When  infection  occurs  during  pregnancy,  owing  to  the  vascularity  of 
the  parts,  the  initial  .sore  assumes  larger  proportions  than  under  ordinary 
circumstances,  while  the  secondary  lesions  are  often  but  slightly  marked. 
The  latter  are  practically  limited  to  the  genitalia,  where  they  appear  as 
large,  elevated  areas  which  occasionally  undergo  ulcerative  changes,  and 
sometimes  lead  to  the  destruction  of  superficial  portions  of  the  vulva. 

The  influence  of  syphilis  upon  pregnancy  differs  materially,  and  three 
classes  of  eases  are  distinguished,  according  as  infection  has  taken  place: 
(1)  before  pregnancy,  (2)  at  the  time  of  conception,  and  (3)  during  preg- 
nancy. 

When  inoculation  with  the  specific  poison  has  occurred  before  con- 
ception, the  disease  nearly  always  gives  rise  to  abortion  or  premature  labour. 
more  frequently  the  latter.  Le  Fileur  obtained  a  striking  illustration  of 
the  disastrous  effects  of  syphilis  from  a  study  of  the  reproductive  his- 
tories of  130  women  before  and  after  its  inception,  3.8  per  cent  of  the 
children  being  born  dead  before,  as  compared  with  78  per  cent  after 
infection. 

In  premature  labour  due  to  syphilis,  the  child  is  usually  dead  when  it 
comes  into  the  world;  less  frequently  it  is  born  alive  with  definite  manifesta- 
tions of  the  disease;  again,  in  a  still  smaller  number  of  cases,  it  is  born 
without  signs  of  the  disease,  which,  however,  make  their  appearance  later; 
while  occasionally,  particularly  when  the  infection  had  occurred  some  years 
previously,  the  child  may  never  manifest  any  signs  of  the  disease. 

When  the  mother  is  infected  at  the  time  of  conception,  the  offspring 
is  always  syphilitic.  Under  such  circumstances,  however,  it  is  a  ques- 
tion  whether  the  child  owes  the  disease  to  paternal  or  maternal  influences. 
On  the  other  hand,  when  syphilis  is  contracted  during  pregnancy  its  effect 
upon  the  foetus  varies.    If  infection  occurs  within  the  first  few  months,  the 


ACCIDENTAL, COMPLICATIONS  OF  PREGNANCY  DUE  TO  DISEASE    441 

foetus,  as  a  rule,  likewise  manifests  signs  of  the  disease,  but  when  it  occurs 
laterjjie  childls  not  ini'ej'tp'1 

In  the  vast  majority  of  cases  IVtal  syphilis  is  (he  result  of  paternal 
infection,  and  many  a  man  suffering  from  the  tertiary  form  has  engen- 
dered a  syphilitic  child  withoul  infecting  his  wife.  In  such  cases  the 
child  may  present  manifest  signs  of  the  disease,  but  the  mother  never- 
theless may  nurse  it  with  impunity,  whereas  it  would  certainly  infect 
another  woman.  This  fact  is  well  stated  in  the  dictum  known  as  Colles's 
law,  the  condition  being  explained  by  a  previous  transmission  of  immunity 
from  the  foetus  to  the  mother.  Not  a  few  syphilographers,  however,  be- 
lieve that  the  mother  is  likewise  infected,  but  without  showing  signs  of  the 
disease,  or  else  suffers  only  from  a  very  attenuated  form — post-conceptional 
gyphjlift-  That  immunity  is  not  always  produced  is  evidenced  by~ those 
rare  instances  in  which  the  mother  is  infected  by  the  child  after  birth. 

The  consideration  of  the  syphilitic  lesions  of  the  child  and  the  pla- 
centa will  be  taken  up  in  the  chapter  upon  Diseases  of  the  Ovum. 

Whenever  we  obtain  a  history  of  syphilis  in  the  mother,  no  matter 
whether  infection  has  occurred  prior  to  or  at  the  time  of  conception, 
radical  specific  treatment  should  at  once  be  instituted,  as  by  its  means  not 
only  may  the  mother  be~cured,  but  at  the  same  time  foetal  transmission 
may  be  avoided. 

In  view  of  the  general  application  of  Colles's  law,  the  syphilitic  child 
should  never  be  given  to  a  wet  nurse,  but  should  be  fed  artificially  in  case 
its  own  mother  is  unable  to  nourish  it. 

Diseases  of  the  Circulatory  and  Respiratory  Systems. — Valvular  Lesions 
of  the  Heart.- — The  occurrence  of  pregnancy  in  women  suffering  from  valv- 
ular disease  of  the  heart  is  generally  believed  to  be  a  most  serious  com- 
plication. Guerard  records  a  mortality  of  28  per  cent,  and  considers  the 
condition  more  alarming  than  even  eclampsia  or  placenta  prsevia.  He 
states  further  that  Schlayer,  Leyden,  Macdonald,  and  Lublinsky  lost  re- 
spectively 48,  54,  60,  and  100  per  cent  of  such  patients.  These  figures, 
however,  apply  only  to  those  cases  in  which  compensation  has  long  since 
failed  and  the  condition  is  complicated  b}^  renal  changes  or  the  toxaemia  of 
pregnancy.  When  all  classes  of  cases  are  considered,  of  course,  the  mor- 
tality is  much  lower. 

Eoutine  examination  shows  that  heart  lesions  are  present  in  a  con- 
siderable proportion  of  cases,  being  observed  by  Demelin  in  1.23,  by  Vinay 
in  2,  and  by  Fellner  in  2.4  per  cent  of  pregnant  patients.  In  a  series  of 
94  cases  Fellner  observed  the  following  lesions: 

Mitral  insufficiency 37 

Mitral  stenosis 5 

Combined  mitral  lesions 34 

Aortic  insufficiency 3 

Aortic  and  mitral  lesions 10 

Uncertain  lesions 5 

Myocarditis 2 

He  also  stated  that  only  one  seventh  of  the  cases  showed  cardiac  mani- 
festations, whereas  Demelin  noted  them  in  two  thirds  of  his  series. 


442  OBSTETRICS 

Even  when  symptoms  are  present,  it  would  appear  that  some  authors 
have  exaggerated  the  seriousness  of  the  condition,  inasmuch  as  the  mor- 
tality noted  by  Fellner  and  Demelin,  in  94  and  41  cases  respectively,  was. 
only  6.3  and  5  per  cent.  From  my  own  experience,  I  should  say  that  one 
or  two  women  in  every  100  present  heart  lesions,  the  majority  of  which, 
however,  do  not  give  rise  to  symptoms.  In  a  small  proportion  of  cases, 
however,  dyspnoea  and  oedema  occur  during  the.  latter  part  of  pregnancy, 
and  occasionally  some  degree  of  collapse  is  noted  shortly  after  labour.  Out 
of  more  than  3,000  cases  of  labour  I  have  seen  only  one  in  which  the 
cardiac  symptoms  were  alarming.  The  patient  was  a  multipara  suffering 
from  uncompensated  mitral  disease,  who  collapsed  in  the  last  month  of 
pregnancy,  with  signs  of  acute  dilatation  of  the  heart  and  intense  pul- 
monary oedema.  Death  was  averted  by  blood-letting  and  the  induction  of 
premature  labour. 

It  is  generally  believed  that  the  most  untoward  symptoms  are  observed 
in  mitral  stenosis.  Lusk  regarded  this  lesion  as  sufficiently  serious  to  war- 
rant the  induction  of  abortion  as  soon  as  the  diagnosis  is  made. 

Generally  speaking,  the  prognosis  is  good  solong  as  compensation  is  re- 
tained.  To  this,  however,  tnere  are  certain  exceptions,  as  Zweifel  has  re- 
corded two  cases  in  which  collapse  and  death  occurred  in  pregnant  women 
who  had  previously  been  absolutely  unaware  of  their  condition.  On  the 
other  hand,  if  compensation  fails,  and  appr^riatetiierapy  does  not  bring 
about  an  amelioration  of  the  symptoms,  the  prognosis~becomes  ominous; 
for  even  if  the  patient  be  saved  from  immediate  death  by  the  induction  of 
premature  labour,  serious  complications  are  usually  in  store  for  her  in  the 
future. 

Grave  heart  lesions  complicating  pregnancy  predispose  to  premature 
labour.  aswas  no  led  hr'20.2  per  cent  of  Fellner's  cases.  This  accident  may 
result  from  uterine  haemorrhage  directly  attributable  to  the  cardiac  con- 
dition, from  the  death  of  tlieN  foetus  due  to  insufficient  oxydation,  or  from 
changes  in  the  placenta.  In  not  a  few  cases  there  is  more  or  less  profuse 
hsemorrhage  immediately  following  delivery;  or  again,  at  the  time  of  labour,, 
owing  to  the  elevation  of  arterial  pressure  incident  to  the  uterine  contrac- 
tions, compensation  may  fail  and  the  woman's  life  may  be  in  peril.  Again, 
collapse  may  manifest  itself  immediately  after  the  expulsion  of  the  child 
as  a  result  of  the  marked  fall  in  the  arterial  pressure  which  occurs  at  that 
time. 

If  the  lesion  is  fairly  compensated  the  patient  should  be  kept  under 
close  observation,  rest  being  ordered  and  digitalis  or  some  other  heart 
tonic  being  employed  as  soon  as  symptoms  appear.  If  this  treatment  fails 
to  bring  about  the  desired  result,  and  the  patient's  life  is  threatened  by 
oedema  of  the  lungs,  bl^je4^etting,  occasionally  gives  excellent  temporary 
results,  and  should  be  f ollowecToy  prompt  evacuation  of  the  uterus. 

The  psychical  disturbances  incident  to  labour,  and  the  elevation  of  arte- 
rial pressure  brought  about  by  the  abdominal  and  uterine  contractions,  ren- 
der  it  advisable  to  make  use  of  an  anaesthetic  during'  th°  ipcourl  stage  As 
soon  as  the  cervix  is  completely  dilated  and  the  head  well  engaged  in  the 
pelvis,  the  termination  of  labour  by  forceps  is  indicated. 


ACCIDENTAL  COMPLICATIONS  OF   PREGNANCY   DUE  TO   DISEASE    443 

Some  authorities  recommend  that  women  suffering  from  heart  lesions 
should  be  dissuaded  from  marriage.  This,  however,  appears  to  be  an  ex- 
treme view,  though,  of  course,  when  the  lesion  is  serious  and  the  compensa- 
tion faulty,  the  dangers  of  ehildbearing  should  he  carefully  explained. 

Myocarditis. — Owing  to  the  difficulty  in  making  an  exact  diagnosis, 
myocarditis  is  rarely  recognised  during  life.  Nevertheless,  it  is  a  most 
serious  complication  of  pregnancy,  and  is  one  of  the  frequent  causes  of 
sudden  death  during  the  second  stage  of  labour  and  the  first  few  hours  of 
the  puerperium. 

Endocarditis. — Acute  endocarditis  may  appear  during  pregnancy,  just 
as  at  other  times.  It  should  always  be  regarded  as  a  serious  matter,  but  par- 
ticularly at  this  time,  as  in  a  small  number  of  cases  theTbactena  'giving  rise 
to  it  may  be  transmitted  to  the  foetus  and  cause  its  death,  while  at  other 
times  small  portions  of  the  vegetations  upon  the  valves  may  be  broken  off 
and  give  rise  to  apoplexy  or  embolism. 

Phlegmasia. — Thrombosis  of  the  veins  of  the  thigh,  or  phlegmasia,  is 

a  very  rare  complication  of  pregnancy.    Brindeau  has  recently  reported  an 

instance  and  refers  to  two  others  in  the  literature.    I  have  seen  one  case. 

It  should  be  regarded  as  a  very  serious  condition,  particularly  in  view  of 

I  the  fact  that  incautious  manipulations  may  lead  to  the  detachment  of 

1  small  particles  of  a  thrombus,  which  may  then  give  rise  to  embolism  of 

the  pulmonary  arteries.     The  symptoms  and  treatment  are  dealt  with  in 

^  Chapters  XLIV  and  XLV. 

Pulmonary  Embolism. — Embolism  of  the  pulmonary  arteries  is  a  very 
rare  complication  of  pregnancy.  Barnes  reports  one  case  which  ended 
fatally  within  a  few  moments,  while  Sperling  has  reported  a  second  which 
eventuated  in  recovery.  The  condition  should  always  be  borne  in  mind  in 
cases  of  sudden  death  during  pregnancy  which  cannot  otherwise  be  ex- 
plained. 

Varices. — Owing  to  the  pressure  of  the  pregnant  uterus  upon  the  veins 
returning  from  the  thighs,  and  the  fact  that  they  are  but  poorly  supplied 
with  valves,  abnormalities  in  their  circulation  are  frequently  observed  dur- 
ing pregnancy,  and  manifest  themselves  by  the  appearance  of  varicose 
veins.  These  may  assume  considerable  proportions  in  the  legs  or  about  the 
vulva,  and  give  rise  to  distressing  symptoms.  In  rare  cases,  particularly 
when  they  are  situated  at  the  vulva,  their  rupture  may  lead  to  fatal  haemor- 
rhage. When  they  occur  in  the  legs,  marked  relief  is  often  obtained  by  the 
use  of  neatly  applied  bandages  or  elastic  stockings.  Active  treatment  is 
useless  in  vulval  varices,  but  the  patient  should  be  cautioned  concerning 
the  danger  of  their  rupture. 

Emphysema. — When  pregnancy  occurs  in  women  suffering  from  ad- 
vanced emphysema,  the  dyspnoea  may  become  so  intense  as  to  demand  its 
artificial  interruption.  In  a  certain  number  of  cases  abortion  or  premature 
labour  occurs  spontaneously,  the  untimely  uterine  contractions  being  at- 
tributed to  insufficient  aeration  of  the  blood. 

Asthma. — The  symptoms  of  asthma  are  sometimes  markedly  aggravated 
during  pregnancy.  In  some  patients  the  disease  makes  its  appearance  only 
during  pregnancy  or  at  the  time  of  labour,  disappearing  spontaneously  after 


444  OBSTETRICS 

childbirth.  If  the  usual  methods  of  treatment  fail,  a  radical  change  of 
air  sometimes  proves  beneficial. 

Dyspnoea. — Almost  every  woman  in  the  last  few  weeks  of  pregnancy 
suffers  more  or  less  from  shortness  of  breath  resulting  from  interference 
with  the  motility  of  the  diaphragm  by  the  enlarged  uterus.  Dyspnoea  oc- 
curring in  the  earlier  months  of  pregnancy  is  usually  due  to  cardiac  or 
renal  disease,  and  demands  a  thorough  physical  examination.  Occasionally 
it  follows  excessive  distention  of  the  uterus,  as  in  hydramnios. 

Diseases  of  the  Alimentary  Tract  and  the  Liver. — Icterus. — Pregnancy 
is  comparatively  seldom  complicated  by  jaundice,  which  is  usually  due  to 
catarrhal  processes  in  the  duodenum.  The  disease  is  generally  without  sig- 
nificance and  undergoes  spontaneous  cure.  In  rare  instances  jaundice  may 
appear  in  successive  pregnancies,  Ahlfeld  having  had  a  patient  in  whom  it 
was  noted  upon  four  occasions. 

Notwithstanding  the  fact  that  in  most  cases  the  jaundice  disappears 
without  treatment,  too  favourable  a  prognosis  should  not  be  ventured,  for 
the  reason  that  now  and  again  the  condition  may  represent  the  initial  symp- 
tom of  acute  yellow  atrophy  of  the  liver. 

Acute  Yellow  Atrophy  of  the  Liver. — This  is  a  very  infrequent  complica- 
tion of  pregnancy,  though  the  latter  appears  to  be  a  predisposing  factor. 
Lomer  noted  that  30  out  of  143  cases  of  acute  yellow  atrophy  coming  to 
autopsy  were  in  pregnant  women.  The  etiology  is  unknown,  but  the  various 
hypotheses  which  have  been  advanced  concerning  it  will  be  found  in  an 
article  by  Wendt. 

Indigestion. — Pregnant  women  very  frequently  suffer  from  indigestion, 
and  the  symptoms  arising  from  it  are  ofttimes  very  distressing.  Such  cases 
should  be  treated  without  reference  to  the  existence  of  pregnancy. 

Constipation. — Owing  to  distention  by  the  growing  uterus,  the  abdom- 
inal walls  may  become  so  impaired  in  tonicity  that  considerable  difficulty 
is  experienced  in  evacuating  the  bowels!"  Indeed,  it  may  be  said  that  the 
majority  of  pregnant  women  suffer  from  constipation.  This  condition 
should  be  carefully  guarded  against  in  order  to  avoid  auto-intoxication 
and  increased  strain  upon  the  kidneys.  It  is  best  overcome  by  appropriate 
diet,  regularity  in  going  to  stool,  and  the  occasional  use  of  pills  of  aloin, 
belladonna,  and  strychnine,  the  fluid  extract  of  cascara,  or  compound  lico- 
rice powder.  The  stronger  cathartics  should  be  avoided  on  account  of  their 
tendency  to  cause  abortion. 

Enteroptosis. — The  neurasthenoid  symptoms  which  so  frequently  ac- 
company enteroptosis,  are  often  markedly  ameliorated  during  pregnancy, 
inasmuch  as  the  steadily  enlarging  uterus  may  tend  to  restore  the  displaced 
viscera  to  their  normal  positions.  The  comfort  of  the  patient  can  be  added 
to  appreciably  by  the  use  of  rational  clothing,  and  especially  by  the  appli- 
cation of  a  properly  adjusted  abdominal_supporter.  The  condition,  how- 
ever, is  prone  to  recur  after  childbirth  unless  the  patient  takes  on  con- 
siderable flesh.  According  to  Maillart  the  improvement  is  sometimes 
permanent,  especially  if  the  relaxation  of  the  abdominal  walls  be  counter- 
acted by  the  use  of  a  snugly  fitting  binder  during  the  puerperium  and  a 
suitable  abdominal  supporter  afterward. 


ACCIDENTAL  COMPLICATIONS  OF    PREGNANCY    DUE  TO    DISEASE    445 

Diseases  of  the  Kidneys  and  Urinary  Tract. — Chronic  Nephritis. —  Preg- 
nancy occurring  in  patients  suffering  from  chronic  nephritis  is  always  a 
serious  complication.  The  disease  rarely  eventuates  in  eclampsia,  though 
the  renal  lesions  may  occasionally  become  so  aggravated  that  uraemic  poi- 
soning  results.  More  frequently,  however,  so  greaj  a  portion  ol  the  pla-"* 
centa  [s  thrown  out  of  function  by  liu'inon-lum/ie  changes,  that  the  lotus 
dies  ami  is  expelled  prematurely,  iliven  wnen  the  placental  changes  are 
not  sufficiently  marked  to  interrupt  pregnancy,  the  foetus  is  often  so 
poorly  developed  that  it  may  weigh  2.000  grammes  or  less  al  birth. 

Many  eases  which  terminate  favourably,  so  far  as  the  pregnancy  is  con- 
cerned, persist  after  the  birth  of  the  child,  and  the  fatal  result  is  some- 
times hastened.  The  treatment  of  chronic  nephritis  will  be  considered 
under  albuminuria  and  the  toxa?mia  of  pregnancy. 

Diabetes. — Formerly  it  was  believed  that  diabetes  was  inconsistent  with 
conception.  This  view  was  combated  first  in  1882  by  Matthews  Duncan, 
who  was  able  to  find  in  the  literature  12  cases  in  which  pregnancy  was 
complicated  by  this  disease.  Later  Partridge  and  Graefe  each  collected 
26  eases  in  which  the  association  was  observed. 

Diabetes  may  exist  before  the  inception  of  pregnancy,  or  may  not 
appear  until  labour.  The  prognosis  is  generally  believed  to  be  ominous 
for  mother  and  child,  but  a  review  of  the  literature  shows  that  less  than 
25  per  cent  of  the  mothers  died  from  diabetic .  coma,  while  premature 
labour  occurred  in  only  one  third  of  the  cases,  pregnancy  going  on  to  term 
in  the  other  two  thirds.  The  only  patient  in  my  practice  presenting  a 
marked  glycosuria  went  on  to  full  term,  and  the  condition  disappeared 
after  labour. 

It  is  interesting  to  note  that  7  of  the  cases  collected  by  Graefe  were 
complicated  by  hydramnios,  and  that  in  5  of  these  sugar  could  be  demon- 
strated in  the  liquor  amnii.  These  observations  suggested  the  possibility 
of  the  fcetal  origin  of  the  glycosuria,  which,  however,  was  distinctly  dis- 
proved in  the  cases  of  Eossa  and  Ludwig,  the  foetal  urine  in  both  being 
free  from  sugar,  although  it  was  readily  demonstrated  in  the  liquor  amnii. 

According  to  Payer,  sugar  is  found  in  the  urine  shortly  before  term 
in  4  per  cent  of  pregnant  women.  Glucose  is  rarely  demonstrated,  whereas 
lactose  or  milk  sugar  is  of  comparatively  frequent  occurrence.  The  pres- 
ence of  lactose  is  simply  a  sign  of  mammary  activity,  and  is  without  sig- 
nificance, while  cane  sugar  is  merely  a  manifestation  of  alimentary  gly- 
cosuria. Payer  has  shown  that  women  are  less  tolerant  of  sugar  during 
pregnancy  than  at  other  times,  as  he  was  able  to  produce  alimentary 
glycosuria  in  80  per  cent  of  his  patients  by  increasing  the  amount  of  sugar 
ingested.  Accordingly,  whenever  sugar  is  present  in  the  urine,  a  prognosis 
should  not  be  expressed  until  it  has  been  determined  whether  one  has 
to  deal  with  glycosuria  or  lactosnria.  as  the  former  is  a  serious  complica- 
tion, whereas  the  latter  is  unattended  by  danger. 

Hematuria. — The  passage  of  bloody  urine  is  rarely  observed  during 
pregnancy,  and  its  occurrence  should  always  lead  one  to  suspect  more  or 
less  serious  lesions  of  the  urinary  tract.  Xevertheless,  Chiaventone  has 
described  an  idiopathic  haematuria  due  to  pregnancy,  and  has  collected  18 


446  OBSTETRICS 

similar  cases  from  the  literature.  He  considers  that  the  hemorrhage  is 
probably  due  to  histological  changes  in  the  kidney  which  result  from  a 
hepato-toxaemia.  He  mentions,  however,  a  case  described  by  Albarran  in 
which  the  bloody  urine  was  probably  due  to  the  presence  of  varicose  veins 
in  the  wall  of  the  bladder. 

Pyelo-nepliritis. — According  to  Vinay,  attention  was  first  called  to  this 
complication  of  pregnancy  by  Keblaud  in  1892.  Since  then  numerous  ex- 
amples have  been  observed,  Vinay  being  able  to  report  9  personal  cases, 
while  Brigand  has  collected  23  instances  from  the  literature,  which  is  well 
reviewed  in  a  recent  article  by  Reed. 

The  disease  usually  appears  in  the  latter  half  of  pregnancy,  when  the 
patient,  who  has  previously  been  perfectly  well,  or  has  merely  complained 
of  slight  vesical  irritation,  is  suddenly  seized  with  intense  paroxysmal 
pains  in  one  renal  region.  This  is  accompanied  by  a  marked  elevation  of 
temperature  and  occasionally  by  chills,  the  temperature  pursuing  a  hectic 
course.  On  palpation  one  kidney  is  found  to  be  markedly  enlarged.  '  After 
a  certain  time  a  large  amount  of  purulent  urine  is  suddenly  passed,  when 
the  pain  disappears  and  the  kidney  becomes  smaller,  the  symptoms  reap- 
pearing as  the  kidney  fills  again.  The  condition  results  from  compression 
of !thejirei£r  by  the  pregnant  uterus,  to  which  must  be  added  an  infectious 
process  which  usually  makes  its  way  upward  from  the  bladder,  though  in 
a  certain  number  of  cases  Vinay  believes  that  the  offending  micro-organ- 
isms are  derived  from  the  intestines. 

The  disease  may  lead  to  death  if  not  alleviated.  The  treatment  con- 
sists of  rest  in  bed  and  an  abundant  but  bland  diet.  The  patient  should 
be  encouraged  to  drink  large  quantities  of  lithia  water,  and  the  usual  renal 
antiseptics  should  be  administered.  If  improvement  does  not  take  place 
and  the  condition  becomes  alarming,  premature  labour  should  be  induced 
without  hesitation,  as  the  emptying  of  the  uterus  removes  the  ureteral 
obstruction  and  allows  of  free  drainage  from  the  kidney  into  the  bladder, 
the  establishment  of  which,  as  a  rule,  is  followed  by  complete  recovery. 
In  two  cases  of  my  own,  the  pain  and  fever  disappeared  immediately  after 
the  induction  of  labour,  the  patients  made  an  uninterrupted  recovery,  nor 
did  the  symptoms  recur. 

Floating  Kidney. — The  symptoms  arising  from  a  movable  or  floating 
kidney  are  usually  considerably  alleviated  during  pregnancy,  as  the  en- 
larged uterus  tends  to  retain  the  kidney  in  its  normal  situation.  In  rare 
instances,  however,  the  pedicle  of  the  kidney  may  become  twisted  and  give 
rise  to  intense  pain,  which  may  be  mistaken  for  renal  colic  or  appendicitis. 
Careful  taxis  will  usually  suffice  for  reduction,  after  which  the  symptoms 
at  once  disappear. 

Owing  to  the  increased  laxity  of  the  abdominal  wall  following  child- 
birth, the  symptoms  are  apt  to  become  aggravated  when  the  patient  gets 
about,  unless  she  has  taken  on  considerable  flesh,  so  that  sufficient  fat  has 
formed  about  the  kidney  to  hold  it  in  place.  A  snugly  applied  bandage 
should  be  worn  throughout  the  puerperium. 

Dislocation  of  the  Kidney. — Cragin  has  reported  an  instance  in  which 
one  kidney  occupied  the  pelvic  cavity,  and  has  collected  5  more  or  less 


ACCIDENTAL  COMPLICATIONS   OF    PREGNANCY    DUE  TO    DISEASE    417 

similar  cases  from  the  Literature.  The  condition  is  rarely  diagnosed  be- 
fore the  ohsel  of  labour,  though  m  Cragin's  case  symptoms  of  incarceration 
led  to  vagina]  examination  and  the  diagnosis  of  the  presence  of  a  tumour, 
which  was  removed  and  found  to  be  ;i  kidney. 

Cystitis. — Pregnancy  is  occasionally  complicated  by  cystitis,  which  is 
usually  due  to  ^mon-lm-al  infection,  though  the  colon  bacillus  may  be  the 
infective  agent.  In  view  of  the  possibility  of  an  ascending  ureteritis  and  a 
resulting  pyelo-nephritis,  the-  condition  demands  prompt  treatment. 

Diseases  of  the  Nervous  System. — I'nnili/sis. — Paraplegia  of  spinal 
origin  occasionally  occurs  during  pregnancy,  while  in  rare  cases  a  patient 
suffering  from  paralysis  may  become  pregnant.  In  either  event  the  con- 
dition is  without  influence  upon  the  course  of  pregnancy,  and  clinical  ex- 
perience teaches  that  labour  in  such  cases  is,  as  a  rule,  easy  and  compara- 
tively painless. 

Neuralgia. — Neuralgic  pains  are  frequent  concomitants  of  pregnancy. 
In  rare  instances  they  are  very  obstinate  and  resist  all  treatment,  though 
they  often  disappear  spontaneously  after  labour.  During  the  later  months 
of  pregnancy  the  head  of  the  child,  after  descending  into  the  pelvis,  may 
frequently  compress  one  or  other  sciatic  nerve  and  give  rise  to  severe 
pain  along  its  course,  "which  is  sometimes  accompanied  by  intense  muscular 
spasm.  Owing  to  its  mode  of  origin,  this  form  of  sciatica  is  not  amenable 
to  treatment. 

•Neuritis. — Winscheid  has  recently  directed  attention  to  an  idiopathic 
neuritis  which  occurs  during  pregnancy.  It  usually  disappears  shortly  after 
childbirth,  and  he  considers  that  the  condition  is  probably  of  toxemic 
origin  and  not  the  result  of  pressure.  The  affection  may  be  limited  to  a 
single  nerve,  or  may  appear  as  a  multiple  neuritis.  It  is  characterized  by 
paralysis  of  the  affected  region  associated  with  muscular  atrophy  and  the 
presence  of  the  characteristic  reaction  of  degeneration.  There  is  marked 
sensitiveness  along  the  course  of  the  affected  nerves,  which  is  frequently  as- 
sociated with  shooting  pains.  Sensibility  of  the  parts  is  markedly  impaired, 
and  the  patients  frequently  suffer  from  parasthesise.  Occasionally  the 
symptoms  are  so  severe  that  the  induction  of  premature  labour  may  be  jus- 
tifiable. 

Chorea. — Pregnancy  occasionally  occurs  in  choreic  individuals,  while 
in  rare  instances  the  disease  does  not  appear  until  after  conception.  In 
the  first  class  of  cases  it  is  comparatively  unimportant,  while  in  the  latter 
the  choreic  movements  are  sometimes  so  intense  as  to  interfere  with  sleep- 
ing or  the  taking  of  food.  In  these  severe  cases  abortion  frequently  occurs, 
and  death  from  exhaustion  may  follow. 

Schrock  has  collected  154  cases  of  chorea  complicating  pregnancy,  with 
a  mortality  of  22  per  cent,  and  Buist  255,  with  a  mortality  of  17.5  per  cent. 
In  view  of  the  serious  prognosis  attending  the  graver  forms  of  the  affection, 
Jolly  recommends  the  induction  of  abortion  or  premature  labour  in  aggra- 
vated cases,  while  Zweifel  goes  so  far  as  to  advocate  its  performance  in  all 
cases  as  soon  as  the  diagnosis  is  made. 

Epilepsy. — This  disease  appears  to  have  no  effect  upon  pregnancy, 
though  at  the  time  of  labour  it  may  be  mistaken  for  eclampsia  by  inex- 


448  OBSTETRICS 

perienced  observers.  If  the  attacks  are  frequent,  the  patient  should  be 
put  upon  large  closes  of  potassium  bromide  and  treated  just  as  at  other 
times.  As  a  rule,  it  is  not  advisable  to  allow  the  mother  to  nurse  her 
child,  as  lactation  sometimes  appears  to  aggravate  the  disease,  while  serious 
injury  might  possibly  be  done  to  the  child  during  an  attack. 

Hysteria. — Hysteria  is  a  not  infrequent  complication  of  pregnancy,  but 
does  not  appear  to  exert  a  deleterious  influence  upon  its  course.  Indeed, 
the  physical  condition  often  undergoes  marked  improvement  at  such  times. 
Occasionally,  however,  the  hysterical  symptoms  may  become  aggravated. 
Many  authors  have  of  late  been  inclined  to  attribute  the  nausea  and  vomit- 
ing of  pregnancy  to  hysteria.  This  is  no  doubt  true  in  many  cases,  but 
certainly  cannot  be  regarded  as  the  sole  cause  of  the  condition. 

Tetany. — In  rare  instances  tetany  may  occur  during  the  course  of  preg- 
nancy, Meinert,  in  1898,  being  able  to  collect  20  cases  from  the  literature. 
In  some  patients  the  disease  appears  only  during  pregnancy  and  is  absent 
at  other  times.  H.  M.  Thomas  observed  a  case  at  the  Johns  Hopkins  Hos- 
pital, in  which  the  condition  had  appeared  in  6  successive  pregnancies. 
A  full  resume  of  the  literature  is  to  be. found  in  his  article. 

The  aetiology  of  tetany  is  not  clear,  though  Thomas  thinks  it  probable 
that  it  is  connected  in  some  way  with  abnormalities  in  the  function  of  the 
thyreoid  gland.  This  was  particularly  manifest  in  one  of  Meinert's  cases. 
The  patient  had  had  nine  normal  pregnancies;  during  the  tenth  she  was 
operated  upon  for  a  goitre  which  seriously  interfered  with  respiration.  The 
disease  "came  on  immediately  afterward  and  persisted  until  after  the  birth 
of  the  child.     It  likewise  reappeared  in  the  eleventh  pregnancy. 

Apoplexy. — Apoplexy  is  rarely  observed  during  pregnancy,  though  it 
is  not  an  infrequent  complication  of  eclampsia.  When  it  occurs  independ- 
ently of  the  latter  disease,  it  is  usually  the  result  of  emboli  due  to  endocar- 
ditis, or  to  phlebitis  of  the  lower  extremities. 

Disturbances  of  Vision. — Disturbances  of  vision  are  rarely  observed 
during  pregnancy,  but  inquiries  should  always  be  made  and  the  patient 
cautioned  concerning  their  diagnostic  significance  if  they  appear.  Amauro- 
sis or  total  blindness  occurring  at  this  time  is  generally  due  to  albuminuric 
retinitis,  and  the  first  indication  of  a  serious  renal  affection  is  sometimes 
afforded  by  an  ophthalmoscopic  examination. 

Diseases  of  the  Blood. — Pernicious  Anwmia.- — According  to  Osier,  this 
complication  was  first  described  by  Channing  in  1842.  Since  then  a  con- 
siderable literature  has  accumulated  upon  the  subject,  which  is  well  re- 
viewed in  Davis's  article.  The  disease  occasionally  appears  during  preg- 
nancy, but  most  frequently  not  until  after  labour.  It  is  characterized  by 
marked  pallor  and  anaemia,  which  is  associated  with  weakness  and  short- 
ness of  breath,  the  extremities  also  becoming  cedematous. 

A  positive  diagnosis  is  made  by  the  microscopical  examination  of  the 
blood,  when  the  number  of  red  blood-cells  is  found  to  be  markedly  dimin- 
ished. Many  of  the  corpuscles  are  irregular  in  shape,  while  nucleated  vari- 
eties are  not  infrequently  observed.  At  the  same  time  there  is  a  relative 
increase  in  the  amount  of  haemoglobin,  though  its  total  amount  is  consid- 
erably below  normal.    As  a  rule,  the  disease  ends  in  death  if  it  be  not  prop- 


ACCIDENTAL  CpAJPLICATIONS   OF   PREGNANCY    DUE  TO   DISEASE    449 

erly  treated,  and  marked  fatty  degeneration  of  the  various  organs  is  found 
at  autopsy.  Excellent  results  are  obtained  by  the  administration  of 
Fowler's  solution  in  increasing  doses,  beginning  with  5  drops  3  times 
a  day. 

Leukcemia. —  Leukaemia  is  a  very  rare  complication  of  pregnancy,  Eer- 
niaii  and  II.  Schroeder  being  able  to  colled  from  the  literature  only  8 
and  1»)  examples  respectively.  In  1  cases  the  disease  had  existed  before  the 
onsel  of  pregnancy,  while  in  the  remainder  it  appeared  after  its  inception. 
It  exerts  uo  direct  effed  upon  gestation,  though  the  association  of  the  two 
conditions  may  seriously  affect  the  mother.  In  several  instances  premature 
labour  resulted,  after  which  the  symptoms  underwent  marked  amelioration. 

The  diagnosis  is  rendered  probable  by  the  existence  of  marked  anaemia 
associated  with  enlargement  of  the  spleen,  and  is  placed  beyond  doubt  by  a 

differential  bl I  count.     Examinations  of  the  foetal  blood  by   Sanger, 

Cameron,  and  Laubenberg  indicate  that  the  characteristic  leucocytes  are 
not  transmitted  to  the  foetus.  In  view  of  the  good  results  which  sometimes 
follow  spontaneous  premature  labour,  pregnancy  should  be  terminated  arti- 
ficially in  serious  cases. 

Hcemophilia. — Although  the  existence  of  a  hemophilic  diathesis  may  be 
without  effect  upon  gestation,  in  the  third  stage  of  labour  it  predisposes  to 
obstinate  post-partum  hemorrhages.  In  view  of  this  danger,  in  the  rare 
cases  in  which  the  conditions  are  associated,  Ivehrer  recommended  the  in- 
duction of  abortion,  though  it  is  probable  that  the  bleeding  would  be  as 
difficult  to  check  after  that  operation  as  after  full-term  labour.  In  a  case 
of  extra-uterine  pregnancy  under  my  observation,  haemophilia  proved  a 
most  serious  complication  at  the  time  of  operation. 

Lead  Poisoning. — C.  Paul  studied  the  histories  of  141  pregnancies  oc- 
curring in  women  suffering  from  chronic  lead  poisoning,  and  found  that 
86  ended  in  abortion  or  premature  labour.  Moreover,  a  large  number  of  the 
children  which  were  born  alive  perished  at  an  early  period,  only  10  per  cent 
remaining  alive  at  the  tenth  year. 

Diseases  of  the  Skin. — Impetigo  Herpetiformis. — According  to  Duhring, 
Hebra  was  the  first  to  call  attention  to  the  serious  nature  of  this  disease. 
Impetigo  herpetiformis  occurs  in  pregnant  women,  and  is  characterized  by 
superficial  pustules,  which  are  arranged  in  groups  or  clusters  with  inflam- 
matory bases.  Xew  lesions  appear  on  the  boraeTs  of  olnh?T~and  crusted  con- 
fluent patches,  while  recovery  takes  place  in  their  centres.  The  lesions 
occur  on  the  trunk,  thighs,  and  in  the  neighbourhood  of  the  genitalia,  but 
rarely  upon  the  face.  They  are  accompanied  by  itching  and  constitutional 
symptoms,  chills  and  high  fever.  The  recorded  mortality  is  about  To  per 
cent,  Debreuihl  having  collected  2-4  cases  occurring  in  Austria  and  Ger- 
many with  18  deaths.  The  disease,  as  a  rule,  does  not  lead  to  abortion  or 
premature  labour,  though  many  of  the  women  affected  with  it  died  unde- 
livered.    The  treatment  is  purely  palliative. 

Herpes  Gestationis. — This  disease,  more  frequently  known  as  dermatitis 
herpetiformis.  "  is  an  inflammatory,  superficially  seated,  multiform,  her- 
petiform  eruption,  which  is  characterized  by  erytheniatous^vesicular,  pus- 
tular, and  bullous  lesions."     It  occurs  occasionally  in  pregnant  women, 


450  OBSTETRICS 

and  is  accompanied  by  marked  burning  and  itching.  It  pursues  a  chronic 
course,  is  often  attended  with  fever,  and  sometimes  ends  in  death. 

Duhring  believes  that  is  probably  toxsemic  in  origin,  though  similar 
lesions  sometimes  occur  during  the  course  of  sepsis.  In  view  of  its  depress- 
ing character,  the  patient  should  be  placed  upon  tonic  treatment,  while  the 
itching  is  best  allayed  by  the  use  of  ointments  or  lotions  containing  oil  of 
cade,  carbolic  acid,  or  similar  substances. 

Pruritus. — Itching  is  often  a  distressing  complication  of  pregnancy.  It 
may  extend  over  the  greater  part  of  the  body  or  be  limited  to  the  genitalia. 
General  pruritus  should  be  regarded  as  a  neurosis,  which  is  probably  toxsemic 
in  origin.  It  often  gives  rise  to  intense  suffering,  the  itching  sometimes 
being  so  constant  that  the  patient  is  unable  to  sleep.  In  some  patients  the 
loss  of  rest  and  the  nervous  strain  attendant  upon  it  exert  a  marked  influ- 
ence upon  the  general  condition.  Such  cases  are  best  controlled  by  the  ad- 
ministration of  nerve  sedatives  and  general  tonic  treatment.  A  rigid  milk 
diet  is  sometimes  followed  by  excellent  results.  When  the  condition  is  not 
amenable  to  treatment  and  the  patient  shows  marked  signs  of  exhaustion, 
the  termination  of  pregnancy  may  be  justifiable. 

Genital  pruritus — pruritus  vulvae — may  be  due  to  several  causes,  among 
which  are  irritating  vaginal  discharges,  parasites^  or  glycosuria.  When 
due  to  the  first-named  cause,  the  condition  is  best  treated  5y  the  adminis- 
tration of  astringent  vaginal  douches  and  the  maintenance  of  absolute 
cleanliness.  At  the  same  time  the  itching  may  be  allayed  by  the  employ- 
ment of  ointments  containing  cocaine,  menthol,  or  carbolic  acid.  Pruritus 
of  diabetic  origin  is  observed  buT"rarely,  but  the  possibility  of  its  occur- 
rence should  always  be  borne  in  mind  and  the  urine  examined.  If  sugar  is 
present,  relief  can  be  obtained  only  .by  placing  the  patient  upon  a  rigid  anti- 
diabetic diet,  while  at  the  same  time  the  appropriate  ointments  should  be 
employed.  Occasionally  intense  itching  about  the  anus  may  be  due  to  the 
presence  of  seat-worms,  which  are  best  destroyed  by  the  use  of  rectal 
enemata  of  infusion  of  quassia.  If  local  measures  prove  ineffectual,  a  dose 
of  5  grains  of  santonin  at  night,  followed  by  Eochelle  salts  the  next  morn- 
ing, will  often  bring  about  the  desired  result. 

Abnormalities  of  Pigmentation. — During  pregnancy  abnormalities  in  pig- 
mentation are  not  infrequently  noted,  which  are  particularly  marked  along 
the  linea  alba  and  about  the  breasts.  In  other  cases  unsightly  yellowish 
splotches — cZoc/swrt^-appear  upon  the  face.  They  are  not  amenable  to 
treatment,  but  usually  disappear  promptly  after  childbirth. 

Accidents  during  Pregnancy. — The  pregnant  woman  is  exposed  to  the 
same  possibility  of  injury  as  at  other  times,  the  prognosis  not  being  ma- 
terially altered  except  that  abortion  frequently  occurs.  Pregnancy  itself 
may  be  complicated  by  accidents  which  are  incident  to  that  condition,  the 
most  important  being  rupture  of  an  extra-uterine  pregnancy,  rupture  of  the 
uterus,  and  premature  separation  of  the  placenta — all  very  serious  compli- 
cations. Their  mode  of  production  and  treatment  will  be  considered  in 
detail  in  the  appropriate  chapters. 

Surgical  Operations  during  Pregnancy. — Formerly  it  was  believed  that 
the  performance  of  surgical  operations  during  pregnancy  would  almost  in- 


ACCIDENTAL  COMPLICATIONS  OF    PREGNANCY    DUE  TO   DISEASE    451 

evitably  bring  aboul  abortion  or  premature  labour,  even  the  extraction  of  a 
tooth  being  considered  a  serious  procedure.  At  present,  however,  thi 
to  anaesthesia  and  a  perfected  surgical  technique,  many  operations  can  be 
performed  at  this  time  with  bu1  Little  additional  risk.  Accordingly,  when- 
ever a  condition  arises  in  the  pregnant  woman  which  imperatively  de- 
mands surgical  treatment,  the  necessary  operation  should  be  performed 
without  hesitation.  At  the  same  time,  it'  the  indication  is  not  pressing,  it 
is  advisable  to  deter  interference  until  after  labour,  so  as  m>t  to  subject 
the  patient  to  an  added  strain. 

A  review  of  the  literature  goes  to  show  that  amputations  are  not  more 
dangerous  than  at  other  times.  Several  observers,  notably  Polk  and  Cragin, 
have  removed  the  kidney  without  terminating  pregnancy,  and  numerous 
eases  are  on  record  in  which  paranephritic  or  broad-ligament  abscesses 
have  been  opened.  Tumours  of  the  generative  tract  can  likewise  be  ex- 
cised without  great  risk  or  markedly  increasing  the  danger  of  premature 
labour.  These  conditions  are  considered  in  the  chapter  upon  the  Compli- 
cation of  Pregnancy  by  Diseases  and  Abnormalities  of  the  Generative  Tract. 

Appendicitis. — Appendicitis  is  a  very  serious  complication  of  pregnancy, 
as  many  women  die  if  not  operated  upon,  while  surgical  procedures  for  its 
relief  are  frequently  followed  by  premature  labour. 

The  diagnosis  is  more  difficult  than  at  other  times,  as  the  enlarged 
uterus  renders  it  almost  impossible  to  explore  the  right  iliac  region  satis- 
factorily. At  the  same  time,  if  a  pregnant  woman  complains  of  pain  in 
the  appendix  region,  associated  with  muscular  spasm  and  an  elevation  of 
temperature  and  pulse,  there  is  usually  but  little  doubt  as  to  the  condition, 
and  surgical  treatment  should  promptly  be  instituted.  Munde,  in  1804, 
was  the  first  to  operate  under  such  circumstances,  and  to  demonstrate  the 
justifiability  of  such  a  procedure.  Since  then  his  advice  has  been  generallv 
followed,  and  an  extensive  literature  has  developed  upon  the  subject.  The 
reader  is  referred  more  particularly  to  the  articles  of  Abrahams,  Gerster, 
and  Pinard. 

LITERATURE 

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223. 
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239-242. 
Ahlfeld  und  aIarchaxd.     Ahlfeld's  Lehrbueh  der  Geburtshulfe.  II.  Aufl.,  1898,  239. 
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Ref.  Centralbl.  f.  Gyn..  1898,  1102. 
Ballaxtyxe  and  Milligax.     A  Case  of  Scarlet  Fever  in  Pregnancy,  with  Infection  of  the 

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30 


452  OBSTETRICS 

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542-552. 
Ruxge.     Die  acuten  Tnfectionskrankheiten  in  atiologischer  Beziehung  zur  Schwanger- 

schaftsunterbrechung.    Yolkmann's  Sammlung  klin.  Vortrage,  Xr.  174. 
Sanger.     LTeber  Leukamie  bei  Schwangerschaft.  etc.     Archiv  f.  Gyn.,  1888,  xxxiii,  161- 

210. 
Schrock.     LTeber  Chorea  gravidarum.     D.  I.,  Konigsberg,  1898. 


454  OBSTETRICS 

Schroeder.      TJeber   wiederholte   Schwangerschaft   bei   linealer  Leukamie.      Archiv  f. 

Gyn.,  1899,  lvii,  26-35. 
Schutz.    Ueber  der  Einfluss  der  Cholera  auf  Menstruation,  Schwangerschaft,  Geburt  u. 

Wochenbett.     Centralbl.  f.  Gyn.,  1894,  1138. 
Speier.     Zur  Kasuistik  des  placentaren  Ueberganges  der  Typhusbacillen  von  der  Mutter 

auf  die  Frucht.     D.  I.,  Breslau,  1897. 
Sperling.    Zur  Kasuistik  der  Embolie  der  Lugenarterie  wahrend  der  Schwangerschaft, 

etc.     Zeitschr.  f.  Geb.  u.  Gyn.,  1893,  xxvii,  439-465. 
Strauss  et  Chamberlent.     Comptes  rendus  de  la  Soc.  de  Biologie,  1882,  novembre  11  et 

decembre  16. 
Thomas.     Tetany  in  Pregnancy.     Johns  Hopkins  Hosp.  Bull.,  1895,  Nos.  50-51. 
Tizzoni  et  Cantani.     Recherches  sur  le  cholera  asiatique.     Ziegler's  Beitrage  zur  path. 

Anat.  u.  zur  allg.  Path.,  1888,  iii,  189-237. 
Vinay.     Maladies  valvulaires  et  grossesse.     Archives  de  Tocologie,  1893,  805. 

Vaccinia  et  variole  au  cours  de  la  grossesse.     Lyon  Med.,  1900,  mars  25. 
Vinay  et  Cade.     La  pyelo-nephrite  gravidique.     L'Obstetrique,  1899,  iv,  230-256. 
Vitanza.     Sulla  transmissibilita  dell'  infezione  colerica  della  madre  al  feto.    Riforma 

medica,  1890,  Nos.  48  and  49. 
Wendt.     Beitrag  zur  Lehre  vom  Icterus  gravis  in  der  Schwangerschaft.    Archiv  f.  Gyn., 

1898,  lvi,  104-128. 
Windscheid.     Neuritis    gravidarum    und    Neuritis    puerperalis.      Graefe's    Sammlung 

zwangloser  Abhandlungen,  1898,  ii,  Heft  8. 
Wolff.     Ueber  Vererbung  von  Infectionskrankheiten.     Virchow's  Archiv,  cxii,  177. 
Zweifel.     Ueber  plotzliche  Todesfalle  von  Schwangeren  u.  Wochnerinnen.     Centralbl.  f. 

Gyn.,  1897,  1-16. 
Kunstlicher  Abortus  bei  Chorea  gravidarum.    Centralbl.  f.  Gyn.,  1901,  1170. 


CHAPTER  XXVI 
COMPLICATIONS  RESULTING  DIRECTLY  FROM   PREGNANCY 

In  the  preceding  chapter  we  considered  the  effect  upon  pregnancy  of 
certain  diseases  which  exist  before  its  inception,  as  well  as  of  others  which 
may  occur  as  accidental  complications  during  its  course.  We  shall  now 
deal  with  certain  disturbances  which  result  directly  from  the  pregnant  con- 
dition itself,  and  are  not  due  to  extraneous  causes. 

Fortunately,  in  the  vast  majority  of  cases  gestation  pursues  a  perfectly 
physiological  course,  and  is  not  attended  by  untoward  symptoms.  At  the 
same  time  there  is  no  other  condition  in  which  the  border  line  between 
health  and  disease  is  less  sharply  marked,  since  a  very  slight  irregularity 
often  suffices  to  convert  a  physiological  and  normal  into  a  pathological  and 
abnormal  state. 

Toxaemia  of  Pregnancy  and  Albuminuria. — It  is  readily  conceivable  that 
the  excretory  functions  are  far  more  liable  to  various  derangements  when 
they  are  called  upon  to  care  for  the  elimination  of  the  waste  products  of 
the  foetal,  as  well  as  of  the  maternal,  metabolism.  For  this  reason  many 
women  who  are  perfectly  well  at  other  times,  suffer  during  pregnane-}*  from 
the  retention  of  certain  excrementitious  substances  which  may  give  rise 
to  an  auto-intoxication  or  toxaemia. 

We  know  very  little  concerning  the  nature  of  the  products  of  the  f  cetal 
regressive  metabolism,  but  these,  whatever  they  may  be,  gain  access  to  the 
maternal  organism  through  the  placenta,  being  eventually  carried  to  the 
liver,  where  they  probably  undergo  further  change,  to  be  finally  excreted 
through  the  kidneys  along  with  the  excrementitious  materials  of  maternal 
origin.  It  is  apparent,  therefore,  that  abnormalities  in  the  functioning  of 
these  organs,  which  under  ordinary  circumstances  might  be  of  but  little 
importance,  may  be  attended  by  serious  consequences  during  pregnancy. 
[Moreover,  it  is  probable  that  heart  lesions,  particularly  degenerative 
changes  in  the  myocardium,  as  well  as  disturbances  in  the  intestinal  func- 
tion, may  predispose  to  such  pathological  conditions. 

From  the  time  of  Bouchard,  the  French  observers  have  insisted  that  all 
pregnant  women  suffer  to  a  greater  or  lesser  extent  from  auto-intoxication, 
the  result  of  the  retention  of  certain  poisonous  substances  in  the  blood,  hold- 
ing that  the  correctness  of  such  a  view  is  clearly  demonstrated  by  an  increase 
in  the  toxicity  of  the  blood  serum  and  a  decrease  in  that  of  the  urine,  as 
shown  by  their  effect  after  injection  into  the  circulation  of  rabbits.     The 

455 


456  OBSTETRICS 

force  of  this  argument,  however,  has  been  greatly  impaired  by  the  recent  in- 
vestigations of  Van  cler  Bergh,  Stewart,  Schumacher,  and  others,  who  have 
shown  that  the  results  of  such  experiments  are  dependent  upon  so  many 
factors  as  to  make  one  sceptical  in  accepting  conclusions  based  upon. them. 

Nevertheless,  there  can  be  no  doubt  that  pregnant  women  frequently 
suffer  from  a  toxaemia,  which  is  accompanied  by  characteristic  changes  in  the 
liver  and  kidneys.  The  hepatic  lesions  are  analogous  to.  but  less  marked 
than  those  occurring  in  eclampsia,  and  consist  of  thrombotic  processes 
which  give  rise  to  focal  necroses,  into  which  haemorrhage  frequently  occurs, 
while  the  renal  changes  are  degenerative  in  character.  The  former  are  so 
characteristic  that  many  French  obstetricians,  notably  Pinard  and  Bouffe 
de  Saint  Blaise,  consider  them  the  primary  cause  of  the  condition,  which 
they  designate  as  hepato-toxcemia.  They  believe  that  in  such  cases  the 
hepatic  metabolism  is  so  interfered  with  that  certain  poisonous  subjstancas, 
ordinarily  rendered  innocuous  in  the  liver,  gain  access  to  the  blood. 

The  German  observers,  on  the  other  hand,  lay  particular  stress  upon  the 
renal  changes.  Leyden  pointed  out  that  degenerative  changes  in  the  epi- 
thelium of  the  uriniferous  tubules  were  of  such  frequent  occurrence  as  to 
justify  one  in  describing  the  "kidney  of  pregnancy"  as  a  pathological 
entity.  This  he  believed  was  brought  about  by  alterations  in  the  arterial 
pressure  and  by  the  interference  with  the  renal  circulation  incident  to 
gestation.  In  a  small  proportion  of  cases  an  acute  parenchymatous  ne- 
phritis is  observed. 

It  is  generally  believed  that  the  frequency  of  renal  involvement  may 
be  approximately  determined  by  ascertaining  the  number  of  cases  in  which 
albumin  can  be  demonstrated  in  the  urine.  Its  presence  was  noted  by 
Trantenroth  and  Saft  in  50  and  5.41  per  cent  of  their  cases  respectively, 
the  former  counting  every  case  in  which  a  trace  of  albumin  could  be  de- 
tected, and  the  latter  only  those  in  which  it  was  present  in  abundance. 

H.  M.  Little  has  tabulated  the  results  of  the  examination  of  the  urine 
in  1,000  pregnant  women  at  the  Johns  Hopkins  Hospital.  Traces  of 
albumin  were  recorded  in  50  per  cent,  and  considerable  quantities  of  albu- 
min, together  with  tube-casts,  in  7.3  per  cent  of  the  cases.  As  the  urine  was 
not  obtained  by  catheterization,  it  is  probable  that  in  many  cases  the  slight 
trace  of  albumin  was  due  to  contamination  by  vaginal  or  urethral  dis- 
charge. On  the  other  hand,  it  appears  permissible  to  assume  that  renal 
lesions  were  present  in  the  cases  in  which  considerable  quantities  of  albu- 
min and  tube-casts  could  be  demonstrated.  These  conclusions  are  still  fur- 
ther substantiated  by  the  subsequent  history  of  the  patients.  In  the  first 
group  there  were  no  serious  disturbances,  whereas  nearly  every  patient  in 
the  second  group  presented  symptoms  of  toxaemia,  which  in  several  in- 
stances eventuated  in  eclampsia  in  spite  of  appropriate  treatment. 

But  even  when  renal  lesions  are  present,  it  does  not  seem  probable  that 
they  constitute  the  primary  etiological  factor  in  the  condition.  My  own  ex- 
perience and  reading  have  led  me  to  the  belief  that  these,  as  well  as  the 
hepatic  changes,  are  due  to  the  circulation  in  the  blood  of  certain  imper- 
fectly oxidized  metabolic  prodricts^with  whose  exact  nature  we  are  as  yet 
unacquainted,  and  that  the  resulting  disturbance  of  function  causes  still 


ToX.KMIA    OF    PREGNANCY 


457 


further  retention  of  the  offending  substances,  thus  giving  pise  to  a  vicious 
circle. 

The  symptoms  of  the  toxaemia  of  pregnancy  may  vary  from  a  -light 
headache  m- nausea  in  one  case  to  a  fatal  attack  of  eclampsia  in  another. 
Mosl  frequently  the  patient  complains  of  a  certain  amount  of  headache, 
lasgjimje,  and  a  diminished  urinary  secretion,  with  which  may  be  asso- 
ciated oedema, of  the  face  or  lower  extremities.  In  other  cases  the  head- 
ache  is  more  severe  and  persistent,  and  may  be  accompanied  by  disturb- 
ances of  vision,  which  sometimes  amount  to  total  blindness:  and  now  and 
again  we  meet  with  a  patient  suffering  from  hallucinations  and  bordering 
on  the  verge  of  insanity.  Again,  in  very  rare  instances,  the  woman  may 
pass  into  a  somnolent  condition,  which  gradually  deepens  into  coma,  usually 
followed  by  death.  Schmorl  has  lately  reported  three  such  cases  In  which 
the  autopsy  revealed  lesions  identical  with  those  observed  in  eclampsia.  I 
have  also  met  with  a  similar  instance.  Somewhat  rarely  the  symptoms  may 
be  identical  with  those  of  an  acute  nephritis.  When  the  toxaemia  is  pro- 
nounced, the  child,  as 
well  as  the  mother,  may 
suffer,  and  in  not  a  few 
cases  the  death  of  the  foe- 
tus is  to  be  attributed  to 
the  condition  (Dienst). 

The  total  amount  of 
urine  may  be  niarTTedly 
diminished,  and  its  ex- 
amination usually  shows 
the  presence  of  a  vari- 
able quantity  of  albumin 
and  casts,  associated  with 
a  diminished  output  of 
urea.  Albumin  and  casts 
are  not  invariably  pres- 
ent: occasionally  a 
marked  diminution  in 
the  amount  of  urea  may 
be  the  only  abnormality. 

Treatment. — In  the 
chapter  upon  The  Man- 
agement of  Pregnancy, 
attention  was  directed  to 
the  necessity  for  the  fre- 
quent and  routine  ex- 
amination of  the  urine. 
Even  in  normal  cases 
these  examinations  should  be  made  once  in  four  weeks  during  the  first  six 
months,  and  every  two  weeks  during  the  last  three  months  of  pregnancy. 
The  patient  should  also  be  cautioned  to  notify  the  physician  whenever  she 
suffers  from  headache,  disturbance  of  vision,  or  cedema. 


Fig.  421. — Esbach's 

Al.BUMIXOJIETER. 


Fig.  422. — DoREiirs's  Ureoiteter. 


458 


OBSTETRICS 


If  the  presence  of  albumin  is  detected,  or  the  physician  does  not  feel  sat- 
isfied with  the  condition  of  the  patient,  the  entire  amount  of  urine  passed 
in  the  twenty-four  hours  should  be  measured,  and  the  total  output  of  albu- 
min and  urea  estimated.  For  practical  purposes,  approximate  results  may  be 
obtained  by  the  use  of  Esbach's  albuminometer  and  Doremus's  ureometer. 

Esbach's  albuminometer  is  a  graduated  test-tube  provided  with  a  stopper 
(Fig.  421).  The  reaction  consists  in  the  precipitation  of  the  albuminous 
substances  by  a  solution  consisting  of  picric  acid  10,  citric  acid  20,  and  dis- 
tilled water  1,000  grammes.  In  order  to  estimate  the  amount  of  albumin, 
the  tube  is  filled  to  the  mark  IT  with  urine  and  afterward  to  E  with  the 
reagent.  It  is  then  corked  and  gently  inverted  ten  or  twelve  times,  after 
which  it  is  allowed  to  stand  for  twenty-four  hours,  when  the  amount  of 


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AMOUNT  OF 
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1575 

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2410 

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3840 

2650 

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2760 

2300 

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2530 

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AMOUNT  OF 
FLUID  BY 
MOUTH. 

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1500 

2750 

3600 

4860 

4500 

4500 

5500 

3150 

5450 

5700 

5040 

4600 

4700 

4100 

4250 

4650 

3100 

4600 

Fig.  423— Urea  Chart. 
Toxaemia  of  pregnancy ;  recovery  under  milk  diet  and  rest  in  bed. 


precipitate  is  read  off  on  the  scale,  each  division  corresponding  to  1  gramme 
of  albumin  to  the  litre. 


Tu\. M.MIA    OF    PREGNANCY 


4. V.» 


Dorenms's  areometer,  which  is  represented  in  Fig.  422,  cnahlcs  one  to 
estimate  indirectly  the  amount  of  urea  after  decomposing  it  by  means  of 
sodium  liypoliiomite,  (lie  reaction  being  shown  by  the  following  formula: 

CON8H*+3NaOBr  =  3NaBr  +  C08  +  2H20  +  N2 

The  potassium  bromide  and  carbon  dioxide  are  dissolved,  while  the  nitro- 
gen gas  rises  to  the  top  of  the  tube,  where  it  can  be  measured. 


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UREA  FOR 
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AMOUNT  OF 
URINE. 

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Fig.  424. — TJeea  Chart. 
Toxaemia  of  pregnancy ;  treatment  without  effect ;  accouchement  force  followed  by  prompt 

recovery. 

In  employing  this  apparatus,  the  large  branch  is  filled  with  a  40-per- 
cent solution  of  caustic  soda,  to  which,  is  added  1  cubic  centimetre  of  bro- 
mine, the  two  together  forming  a  fresh  solution  of  sodium  liypobromite. 
After  the  mixture  has  settled,  the  shorter  branch  is  filled  with  urine,  and 
by  turning  the  stop-cock  1  cubic  centimetre  of  it  is  allowed  to  enter  the 
longer  branch.  Its  admission  is  followed  by  an  active  formation  of  gas, 
which  drives  part  of  the  fluid  out  of  the  tube  into  the  adjoining  bulb.  When 
the  process  is  completed,  the  amount  of  nitrogen  formed  is  read  off  from 
the  scale,  each  division  indicating  the  presence  of  0.001  gramme  of  urea 
to  each  cubic  centimetre  of  urine.  From  this  the  total  amount  in  the 
specimen  is  readily  calculated. 


460  OBSTETRICS 

Ordinarily,  if  the  urea  output  is  normal  (20  to  24  grammes  per  diem),  the 
presence  of  a  slight  amount  of  albumin  may  be  regarded  with  indifference; 
whereas,  if  a  considerable  quantity  is  present  and  the  urea  at  the  same 
time  falls  considerably  below  normal,  the  patient  should  be  regarded  as  in 
serious  clanger  and  should  be  kept  under  close  supervision.  During  this 
time  the  twenty-four-hour  specimen  of  urine  should  be  examined  daily, 
and  the  treatment  based  upon  the  relative  amounts  of  albumin  and  urea 
present,  as  well  as  upon  the  subjective  symptoms.    (See  Figs.  423  and  424.) 

The  patient  should  be  put  to  bed,  or  at  least  confined  to  her  room  and 
placed  upon  a  restricted  diet,  meats  and  the  stronger  vegetables  being 
interdicted;  or,  better  still,  for  a  while  she  should  depend  solely  upon  milk, 
which  is  not  only  an  excellent  food,  but  also  a  most  efficient  diuretic.  At 
least  two  quarts  should  be  consumed  in  the  twenty-four  hours.  To  relieve 
the  monotony,  she  may  be  allowed  small  quantities  of  lettuce  salad,  bread 
and  butter,  and  occasionally  a  little  herring  roe  as  a  relish.  She  should 
also  be  made  to  take  considerable  quantities  of  fluid  in  the  shape-  of  plain 
water,  Buffalo  lithia  water,  or  cream  of  tartar  lemonade  (1  dram  to  the 
pint). 

In  most  cases  this  treatment  will  be  followed  by  a  marked  amelioration 
of  the  symptoms,  an  increased  urinary  secretion,  a  decrease  in  the  amount  of 
albumin,  a  rise  in  the  amount  of  urea,  and  a  prompt  return  to  normal  condi- 
tions (Fig.  423).  If  the  desired  result  is  not  accomplished,  a  brisk  purge  of 
Rochelle  or  Epsom  salts  should  be  given  daily,  and  the  cutaneous  functions 
stimulated  by  a  daily  hot  pack  or  sweat  bath.  If  under  treatment  the 
symptoms  disappear,  the  albumin  becomes  less  and  the  urea  increased  in 
amount,  the  outlook  may  be  considered  excellent.  On  the  other  hand, 
if  the  albumin  steadily  increases,  and  the  urea  decreases  in  amount,  while 
the  subjective  condition  of  the  patient  remains  unchanged,  the  prognosis 
becomes  ominous,  and  the  appearance  of  somnolence  and  coma  or  eclamp- 
sia can  probably  be  avoided  only  by  the  induction  of  premature  labour,  no 
matter  what  be  the  period  of  pregnancy  (Fig.  424). 

In  what  has  been  said  concerning  the  diagnostic  value  of  the  deter- 
mination of  the  relative  amounts  of  urea  and  albumin  in  the  urine,  we 
have  not  intended  to  convey  the  impression  that  the  toxsemia  results  from 
the  retention  of  urea.  Nevertheless,  the  estimation  of  the  latter  affords  a 
convenient  clinical  index  as  to  the  amount  of  waste  material  that  is  being 
excreted.  In  hospital  practice  a  more  accurate  criterion  is  afforded  by  the 
total  amount  of  nitrogen  excreted  during  the  twenty-four  hours,  and  par- 
ticularly the  relation  which  it  bears  to  the  nitrogen  contained  in  the  urea. 

Eclampsia. — "When  the  symptoms  of  toxaemia  do  not  disappear  under 
the  treatment  just  outlined,  it  is  probable  that  eclampsia  will  shortly 
supervene.  The  consideration  of  this  condition,  however,  will  be  taken  up 
in  Chapter  XL. 

Pernicious  Vomiting  of  Pregnancy. — Hyveremesis. — Reference  has  al- 
ready been  made  to  the  nausea  and  vomiting  which  so  frequently  accom- 
panies pregnancy — the  so-called  morning  sickness.  This  symptom  is  more 
or  less  marked  in  almost  one  half  of  the  cases;  it  usually  makes  its  appear- 
ance about  the  sixth  week,  disappearing  spontaneously  about  the  twelfth  or 


.PERNICIOUS  VOMITING   OP   PREGNANCY  461 

fourteenth  week  of  pregnancy.  In  other  cases  it  persists  for  a  longer 
period,  and  occasionally  continues  up  to  term.  If  the  vomiting  occurs 
only  in  the  early  morning,  as  is  usually  the  case,  and  does  not  materially 
interfere  with  the  ingestion  of  food,  it  must  be  regarded  rather  as  an  an- 
Qoying  than  as  a  serious  complication. 

On  the  other  hand,  about  once  in  1. 000  cases,  according  to  Pick,  the 
patient  is  constantly  nauseated,  and  vomits  whenever  she  attempts  to  take 
food.  This  pernicious  vomiting  of  pregnancy,  or  hyperemesis,  as  it  is 
termed,  constitutes  a  most  serious  affection,  and  according  to  Merle  ter- 
minates fatally  in  nearly  50  per  cent  of  the  cases  which  are  subjected  to 
purely 'medicinal  treatment.  At  first  the  patient  suffers  merely  from  the 
discomfort  incident  to  the  condition,  but  in  a  short  time,  owing  to  the 
inability  to  retain  nutriment,  she  begins  to  show  signs  of  malnutrition  and 
eventually  those  of  actual  starvation.  Rapid  emaciation  occurs,  the  face 
assumes  a  drawn  and  haggard  aspect,  and  the  skin  may  become  slightly 
jaundiced.  The  pulse  increases  in  rapidity  and  the  temperature  becomes 
elevated,  sometimes  reaching  103°  to  104°  F.  The  fever  is  variously 
interpreted,  but  is  probably  indicative  of  the  onset  of  a  terminal  infec- 
tion. When  this  stage  of  the  disease  is  reached  the  outlook  becomes 
gloomy,  as  death  will  probably  result,  no  matter  what  treatment  may  be 
instituted. 

/Etiology. — That  a  vast  literature  has  accumulated  as  to  the  causation 
and  treatment  of  the  affection  goes  to  prove  that  it  is  not  dependent  upon 
a  single  etiological  factor.  Kaltenbach,  Klein,  and  many  recent  writers 
consider  it  a  neurosis,  which  is  more  or  less  allied  to  hysteria,,,  and  base 
their  belief  upon  the  fact  that  its  cure  is  frequently  effected  by  suggestion 
or  moral  suasion.  At  the  same  time  they  advocate  placing  the  patient  at 
absolute  rest  and  excluding  all  forms  of  excitement,  while  small  amounts 
of  nutritive  and  easily  digestible  food  are  administered  at  frequent  in- 
tervals. In  several  cases  under  my  observation,  the  neurotic  nature  of 
the  condition  was  clearly  demonstrated.  One  patient,  who  had  vomited 
incessantly  for  several  weeks,  was  promptly  cured  after  I  had  drawn  an 
alarming  picture  of  the  dangers  incident  to  abortion,  which  I  told  her 
must  inevitably  be  induced  if  she  did  not  improve  within  the  next  twenty- 
four  hours.  Many  similar  cases  are  reported  in  which  permanent  cure 
followed  simple  methods,  and  was  manifestly  the  result  of  suggestion. 

Of  late  years  there  has  been  an  increasing  tendency  to  attribute  certain 
cases  of  hyperemesis  to  the  toxaemia  of  pregnancy.  Lindemann,  Dirmoser, 
Champetier  de  Eibes  and  Bouffe  de  Saint  Blaise  have  reported  fatal  cases 
in  which  the  autopsy  showed  lesions  of  the  liver,  kidneys,  and  other 
organs  identical  with  those  observed  in  eclampsia. 

In  many  cases  the  condition  is  clearly  the  result  of  reflex  irritation, 
which  has  its  origin  in  certain  abnormalities  of  the  generative  tract.  Thus, 
it  is  sometimes  associated  with  an  incarcerated  retrofiexed  uterus,  the 
symptoms  disappearing  immediately  after  the  organ  is  freed  from  its  ab- 
normal position.  Again,  a  similar  beneficial  result  has  followed  the  closure 
of  deep  cervical  tears.  More  frequently,  the  vomiting  is  attributable  to  the 
existence  of  endometritis,  more  or  less  recent  inflammatory  processes  affect- 


462  OBSTETRICS 

ing  the  tubes  and  ovaries,  especially  when  they  are  bound  down  by  adhe- 
sions, extra-uterine  pregnancy,  lrydranrnios,  or  other  complications. 

Sometimes  lesions  of  other  organs  are  responsible,  the  condition  being 
observed  in  women  suffering  from  anamiia  or  gastric  ulceration,  and  dis- 
appearing with  the  cure  of  the  underlying  affection.  Davis  reports  a  case 
which  apparently  resulted  from  cerebral  metastases  following  a  deciduoma 
malignum.  Chronic  pancreatitis  appeared  to  have  been  the  primary  cause 
in  a  fatal  case  under  my  observation.  Full  literature  upon  the  aetiology  of 
the  affection  may  be  found  in  the  exhaustive  monograph  of  Pick. 

Treatment. — The  fact  that  a  large  proportion  of  the  remedies  in  the 
pharmacopoeia  have  been  recommended  for  the  treatment  of  the  vomiting 
of  pregnancy,  is  abundant  evidence  that  drugs  are  often  unavailing.  Sat- 
isfactory results  are  sometimes  obtained  from  one  or  other  of  the  following: 
Capsules  containing  4  grain  of  nitrate  of  silver  and  2  grains  of  pepsin, 
or  2  grains  of  menthol,  rljtn_te  hjajpacgzanixi  apjrl,  small  doses  of  cocaine, 
drop  doses  of  the  tincture  of  iodine,  subnitrate  of  bismuth,  or  oxalate  of 
cerium,  either  in  the  form  of  5-grain  powders  or  the  effervescent  prepara- 
tion. Occasionally  the  first  remedy  prescribed  will  lead  to  a  marked  ame- 
lioration of  the  symptoms,  while  in  other  cases  the  whole  gamut  may  be 
prescribed  in  succession  without  appreciable  result. 

When  the  condition  is  serious  the  patient  should  be  subjected  to  a 
careful  physical  examination,  and  if  any  abnormality  is  detected,  whether 
in  the  generative  tract  or  elsewhere,  the  treatment  should  be  directed  to 
its  removal  or  correction.  In  a  few  cases  the  application  of  nitrate  of 
silver  or  of  the  tincture  of  iodine  to  the  cervical  canal,  or  its  moderate 
dilatation  by  means  of  a  steel  dilator  or  a  small  pack,  seems  to  effect 
a  cure,  though  the  possibility  of  suggestion  should  always  be  borne  in 
mind. 

Excellent  results  are  sometimes  obtained  by  treating  the  condition  as  a 
•pure  neurosis,  with  rest  in  bed,  avoidance  of  excitement,  moral  suasion, 
and  particularly  the  administration  of  small  quantities  of  easily  digestible 
food  at  frequent  intervals  and,  when  nothing  is  retained  by  the  stomach, 
the  employment  of  nutritive  rectal  enemafo.  High  injections  of  large 
quantities  of  normal  salt  solution,  once  or  twice  daily,  are  very  valuable  for 
allaying  the  thirst  from  which  the  patient  so  often  suffers.  Occasionally 
an  examination  of  the  urine  will  show  that  we  have  to  deal  with  an  auto- 
intoxication. In  such  cases  the  treatment  previously  outlined  may  give 
good  results. 

Unfortunately,  the  conscientious  employment  of  the  methods  of  treat- 
ment here  suggested  is  sometimes  of  no  avail,  and  the  patient  becomes  pro- 
gressively worse  until  she  appears  to  be  on  the  verge  of  death  from  starva- 
tion. Under  such  circumstances  the  only  hope  of  saving  her  life  lies  in 
emptying  the  uterus,  and  abortion  should  be  induced  before  her  condition 
becomes  desperate.  Owing  to  the  uncertain  nature  of  the  affection,  and  the 
fact  that  not  a  few  cases  recover  spontaneously  at  the  last  moment,  it  is  only 
natural  that  the  physician  should  defer  such  a  procedure  as  long  as  pos- 
sible; but,  unfortunately,  this  laudable  desire  has  not  infrequently  resulted 
in  postponing  interference  so  long  that  the  operation  has  been  performed 


COMPLICATIONS   RESULTING   DIRECTLY    PROM    PREGNANCY      463 

too  late  to  prevent  a  fatal  issue.  I  have  seen  several  cases  in  consultation 
in  which  fche  death  of  the  patient   was  undoubtedly  due  to  this  delay. 

Hence,  although  general  therapeutic  measures  should  he  given  a  thorough 
trial,  care  should  he  taken  to  empty  the  uterus  while  the  patient  has  -till 
a  chance  of  surviving  the  operation.  Full  literature  concerning  the  induc- 
tion of  abortion  under  such  eireumstances  will  he  found  in  Merle's  article. 

Sali  rat  ion. — In  exceptional  instances  the  salivary  secretion  becomes 
markedly  increased  during  pregnancy.  As  a  rule,  this  is  not  a  serious  com- 
plication, but  now  and  again  the  amount  of  saliva  is  so  great  as  to  cause  the 
patient  great  annoyance,  and  sometimes  even  prevent  her  from  sleeping. 
One  of  my  own  patients  expectorated  between  500  and  600  cubic  centi- 
metres of  clear  fluid  every  day  for  several  weeks,  while  Lvoff  has  reported 
several  cases  in  which  the  secretion  in  the  twenty-four  hours  varied  from 
1,000  to  1,600  cubic  centimetres. 

The  condition  is  usually  attributed  to  a  reflex  neurosis  incident  to 
pregnancy,  but  sometimes  it  is  a  manifestation  of  auto-intoxication.  In 
the  first  class  of  cases  the  treatment  is  very  unsatisfactory,  astringent 
mouth  washes,  and  even  comparatively  large  doses  of  atropine,  being  with- 
out effect.  On  the  other  hand,  when  the  condition  results  from  auto- 
intoxication, marked  amelioration  frecpiently  results  from  placing  the  pa- 
tient upon  a  rigorous  milk  diet. 

Gingivitis. — Exceptionally,  the  gums  of  pregnant  women  become  in- 
flamed and  spongy,  and  bleed  upon  the  slightest  touch.  The  condition  is 
usually  observed  in  run-down  individuals,  and  is  very  refractory  to  treat- 
ment, although  in  many  cases  it  disappears  almost  immediately  after  de- 
livery. It  is  best  met  by  the  employment  of  astringent  mouth  washes, 
especially  those  containing  tincture  of  myrrh,  combined  with  general  tonic 
treatment  and  an  abundant  diet. 

Dental  Caries — Toothache. — Many  women  suffer  during  pregnancy 
from  dental  caries,  which  is  associated  with  more  or  less  severe  toothache. 
It  is  a  popular  belief  that  pregnancy  predisposes  to  the  condition,  as  is  evi- 
denced by  the  saying,  "  For  every  child  a  tooth."  It  is  probable  that 
the  condition  is  somewhat  allied  to  the  minor  degrees  of  osteomalacia  which 
occur  only  during  pregnancy.  Such  patients  should  be  referred  to  a  skilful 
dentist,  and  at  the  same  time  should  be  placed  upon  the  sirup  of  the 
hvpophosphifes  or  the  lactophosphate  of  lime. 

(Edema. — CEdema  is  a  very  frequent  complication  of  pregnancy.  It 
may  be  general  and  involve  any  portion  of  the  body,  but  is  usually  limited 
to  the  lower  extremities.  Occasionally  the  vulva  becomes  intensely 
cedematous.  TThen  limited  to  the  extremities,  the  swelling  probably  results 
from  pressure  exerted  by  the  enlarged  uterus  upon  the  veins  returning  from 
the  legs.  On  the  other  hand,  if  it  be  generalized,  it  is  likely  to  be  a  mani- 
festation of  toxa?mia,  or  even  of  an  acute  nephritis,  though  occasionally  it 
may  be  due  to  other  causes.  Similarly,  oedema  of  the  vulva  may  be  purely 
mechanical  or  a  manifestation  of  some  systemic  disturbance. 

The  patient  should  be  cautioned  as  to  the  significance  of  oedema,  and 
whenever  it  appears  the  urine  should  be  carefully  examined.  If  the  kidneys 
are  found  to  be  doing  their  work  properly,  the  swelling  is  probably  of 


464 


OBSTETRICS 


mechanical  origin  and  usually  is  not  amenable  to  treatment,  though  the 
condition  may  be  markedly  benefited  by  restricting  the  movements  of  the 
patient,  or  even  confining  her  to  her  bed.     If  the  urine  be  abnormal,  the 


Fig.  425. — (Edema  of  Vulva. 


condition  is  more  serious,  and  the  woman  should  be  subjected  to  the  treat- 
ment already  outlined  for  the  toxaemia  of  pregnancy. 

When  the  marked  swelling  about  the  vulva  is  a  source  of  discomfort  and 
annoyance,  and  is  not  relieved  by  medicinal  treatment,  relief  may  be  given 
by  puncturing  the  most  dependent  portions  of  the  swollen  labia  and  allow- 
ing the  serum  to  drain  off.  This  slight  operation  should  always  be  done 
under  the  strictest  aseptic  precautions,  and  the  labia  afterward  covered 
with  sterile  dressings,  inasmuch  as  infection  can  readily  occur  and  may  be 
followed  by  serious  consequences. 

Goitre. — "We  have  already  referred  to  the  slight  enlargement  which  the 
thyroid  frequently  undergoes  during  pregnancy.  Bignami  has  reported 
a  case  which,  in  his  opinion,  proved  that  pregnancy  occasionally  exerts  a 
pathological  influence  upon  this  gland.  During  his  patient's  first  preg- 
nancy the  thyroid  underwent  considerable  hypertrophy  ,^but  returned  to  its 
normal  size  after  delivery.  The  condition  returned  in  the  second  preg- 
nancy, the  enlargement  reaching  such  proportions  that  death  resulted  from 
suffocation. 

In  rare  instances  pregnancy  appears  to  cause  a  rapid  increase  in  the 
size  of  a  thyroid  tumour,  which  had  been  present  before  its  inception. 


COMPLICATIONS   RESULTING    DIRECTLY    PROM    PREGNANCY      465 

Ahlfeld,  Aibers-Schdnberg  and  Meinert  have  reported  cases  in  which  a 
goitre,  which  had  previously  grown  only  slowly  or  had  remained  stationary 
in  size,  became  so  large  during  pregnancy  as  to  render  tracheotomy  or  the 
operative  removal  of  the  growth  necessary  in  order  to  prevent  deatli  from 
suffocation. 

Mental  Derangements  and  Insanity. — Pregnancy  is  frequently  accom- 
panied by  slight  emotional  or  mental  disturbances,  many  women  becoming 
very  irritable  at  such  times.  In  rare  instances  the  disturbances  may  be- 
come emphasized  and  the  patients  suffer  from  delusions,  and  occasionally 
from  actual  insanity.  This  is  often  a  manifestation  of  auto-intoxication, 
which  yields  readily  to  appropriate  treatment,  although  now  and  again  the 
condition  may  eventuate  in  permanent  insanity. 

I  recall  one  patient  wdio  during  the  later  months  of  pregnancy  suffered 
from  delusions  of  persecution.  At  such  times  large  amounts  of  albumin 
were  present  in  the  urine,  while  the  urea  output  was  greatly  diminished. 
Sweat  baths  were  repeatedly  followed  by  an  immediate  improvement  in. 
the  condition  of  the  urine,  after  which  the  mental  condition  became  normal,! 
the  delusions  reappearing,  however,  within  a  few  days,  to  again  disappear' 
under  the  same  treatment.     Complete  recovery  followed  delivery. 

Relaxation  of  the  Pelvic  Joints. — Owing  to  the  great  vascularity  incident 
to  pregnancy,  the  various  pelvic  joints  always  show  a  somewhat  increased 
motility.  In  rare  instances,  however,  the  softening  of  the  interarticular 
cartilage  at  the  symphysis  pubis  admits  of  such  abnormal  motion  in  the 
joint  as  to  interfere  seriously  with  the  comfort  of  the  patient,  who  suffers 
from  intense  dragging  pains  in  the  pelvis  and  lower  abdomen,  while  at  the 
same  time  the  gait  may  be  so  profoundly  altered  as  to  suggest  the  possible 
presence  of  cerebral  or  spinal  trouble.  In  such  cases  the  application  of  a 
tightly  fitting  bandage  about  the  thighs  is  followed  by  marked  improve- 
ment, though  occasionally  the  symptoms  are  so  pronounced  that  the  patient 
is  obliged  to  take  to  her  bed.  Occasionally  the  condition  persists  for  a 
considerable  time  after  childbirth.  The  whole  subject  has  been  studied  in 
detail  by  Cantin  (1899). 

Hematoma  of  the  Abdominal  Walls. — Stoeckel  has  reported  two  cases 
of  hematoma  of  the  abdominal  walls  occurring  during  pregnancy.  In  one 
case  the  tumour  was  situated  in  the  sheath  of  the  right  rectus  muscle  just 
above  the  symphysis,  while  in  the  other  it  appeared  as  a  large  mass  in 
the  right  hypogastric  region,  which  was  mistaken  for  the  head  of  the  child. 
The  condition  resulted  from  rupture  of  the  inferior  and  superior  epigastric 
artery  respectively. 


LITERATURE 

Ahlfeld.     Schwangerschaft  unci  Geburt  complieirt  durch  Struma.     Berichte  u.  Arbeiten, 

1885,  ii,  181. 
Albers-Schonberg.     Kompression  der  Trachea  in  Folge  von  Schilddrusensehwellung  in 

der  Graviditas  Tracheotoraie.  Centralbl.  f.  Gyn.,  1895,  454-458. 
Bignami.  Tiroidismo  e  gravidanza.  Ref.  l'Obstetrique,  1896,  i,  174. 
Bouchard.     Lecons  sur  l'autointoxication.     Paris,  1887. 


466  OBSTETRICS 

Bouffe   de   Saint   Blaise.    Les  autointoxications  gravidiques.     Annales  de   Gyn.  et 

d'Obst.,  1898,  1,  342-374  et  432-455. 
Cantin.     Relachement  des  symphyses  et  arthralgies  pelviennes  d'origine  gravidique. 

These  de  Paris,  1899. 
Champetier  de  Ribes  et  Bouffe  de  Saint  Blaise.     Note  sur  un  cas  de  vomissements 

incoercibles  avec  autopsie.     Comptes  rendus  de  la  Soc.  de  Gyn.,  d'Obst.,  et  de  Ped. 

de  Paris,  1901,  iii,  195-197. 
Davis  and  Harris.     Syncytioma  Malignurn  and  Ectopic  Gestation  causing  Pernicious 

Nausea,     Trans.  Amer.  Gyn.  Soc,  1900,  xxv,  364-389. 
Dienst.     Kritische  Studien  iiber  die  Pathogenese  der  Eklampsie,  etc.     Archiv  f.  Gyn., 

1902,  lxv,  369-464. 
Dirmoser.     Der  Vomitus  gravidarum  perniciosus.     Wien,  1901. 
Kaltenbach.    Ueber  Hyperemesis  gravidarum.    Zeitschr.  f.  Geb.  u.  Gyn.,  1891,  xxi,  200- 

208. 
Klein.     Hyperemesis  gravidarum.     Zeitschr.  f.  Geb.  u.  Gyn.,  1898,  xxxix,  75-98. 
Leyden.     Einige  Beobachtungen  iiber  Nierenaffectionen,  welche  mit  Schwangerschaft  im 

Zusammenhang  stehen.     Zeitschr.  f.  klin.  Med.,  1881,  ii,  171-191. 
Lindemann.     Zur  path.  Anat.  des  unstillbaren  Ei-brechens  der  Schwangeren.  •  Centralbl. 

f.  allg.  Path.  u.  path.  Anat.,  1893,  Nr.  15. 
Lvoff.     Ptyalismus  perniciosus  gravidarum.     Ref.  Frommel's  Jahresbericht,  1896,  595. 
Meinert.     Fall  von  Tetanie  in  der  Schwangerschaft,  entstanden  nach  Kropfoperation. 

Archiv  f.  Gyn.,  1898,  lv,  446-453. 
Merle.     De  l'avortment  force  dans  vomissements  incoercibles  graves.     L'Obstetrique, 

1900,  v,  230-252. 

Pick.     Ueber  Hyperemesis  gravidarum.     Volkmamrs  Sammlung  klin.  Vortrage,  N.  F., 

1902,  Nrs.  325-326. 
Saft.     Beitrag  zur  Lehre  von  der  Albuminurie  in  der  Schwangerschaft,  etc.,  und  von 

ihren  Verhaltniss  zur  Eklampsie.     Archiv  f.  Gyn.,  1896,  li,  206-249. 
Schmorl.     Zur  Lehre  von  der  Eklampsie.     Archiv  f.  Gyn.,  1902,  lxv,  504-529. 
Schumacher.     Exp.  Beitrage  zur  Eklampsie-frage.     Hegar's  Beitrage  zur  Geb.  u.  Gyn., 

1901,  v,  257-309. 

Stewart.     Toxicity  of  Urine  in  Pregnancy.     Amer.  Jour.  Obst.,  1901,  xliv,  506-575. 
Stockel.     Zwei  Falle  von  Bauchdeckenhamatom  in  der  Schwangerschaft,     Centralbl.  f. 

Gyn.,  1901,  241-246. 
Trantenroth.     Studien  iiber  das  Verhalten  der  Harnorgane,  insbesondere  der  Nieren,  in 

Schwangerschaft,  etc.     Zeitschr.  f.  Geb.  u.  Gyn.,  1894,  xxx,  98-175. 
Van  der  Bergh.    Ueber  die  Giftigkeit  des  Harns.     Zeitschr.  f.  klin.  Med.,  1898.  xxxv, 

52-79. 


CHAPTER    XXVII 

COMPLICATIONS   DUE   TO   DISEASES  AND  ABNORMALITIES   OF 
THE   GENERATIVE   TRACT 

Diseases  of  the  Vulva  and  Vagina. — Varices. — Varicose  veins  sometimes 
appear  in  the  lower  part  of  the  vagina,  but  are  more  common  around  the 
\iil\;i,  where  they  may  attain  considerable  proportions  and  give  rise  to  a 
sensation  of  weight  and  discomfort.  Treatment  has  practically  no  effect 
upon  the  local  condition.  In  rare  instances  the  varices  may  rupture  during 
pregnancy,  though  this  accident  is  more  frequently  observed  at  the  time  of 
labour,  when  profuse  and  sometimes  fatal  haemorrhage  may  result  if  appro- 
priate surgical  treatment  is  not  available. 

Inflammation  of  Ba rth alin 's  Gla n ds. — Infectious  micro-organisms  may 
gain  access  to  Bartholin's  glands  and  give  rise  to  abscess  formation.  In 
such  cases  the  labium  majus  on  the  side  affected  becomes  swollen  and 
painful,  and  on  examination  is  found  to  inclose  a  large  collection  of  pus. 
Most  often  the  infection  is  gonorrhoea!  in  origin,  though  other  bacteria 
are  sometimes  associated  with  the  gonococcus.  Aside  from  the  pain  and 
discomfort,  this  complication  is  always  a  possible  source  of  danger  during 
labour  and  the  puerperium,  since  it  may  be  the  starting-point  of  a  puerperal 
infection.  For  these  reasons,  whenever  a  labial  abscess  develops  during 
pregnancy  it  should  be  opened  up  and  drained;  or,  better  still,  the  entire 
pus  sac  should  be  excised. 

Relaxation  of  the  Vaginal  Outlet. — In  multiparous  women  the  congestion 
incident  to  pregnancy  not  uncommonly  causes  the  anterior  or  posterior 
vaginal  wall  to  protrude'  through  the  relaxed  or  torn  outlet  as  a  distinct 
cystocele  or  rectocele.  This  condition  is  generally  associated  with  drag- 
ging pains  in  the  back  and  lower  abdomen,  and  often  interferes  with  loco- 
motion. It  is  not  amenable  to  treatment  during  pregnancy,  though  the 
symptoms  may  be  temporarily  relieved  by  rest  in  bed. 

Vaginitis. — This  complication  has  already  been  considered  in  Chapter 
XXV,  under  the  heading  of  Gonorrhoea. 

Colpo-hi/perplasia  cystica. — This  rare  condition,  first  described  by 
Winckel,  is  characterized  by  the  presence  in  the  vaginal  mucosa  of  numerous 
small  cavities  filled  with  clear  fluid  or  gas  and  forming  elevations  upon 
its  surface.  Although  not  amenable  to  treatment  during  pregnancy,  it 
usually  disappears  soon  after  childbirth.  The  recent  researches  of  Linden- 
thai  render  it  probable  that  the  disease,  in  many  cases  at  least,  is  due  to 
infection  with  B.  aerogenes  capsulatus. 

31  "  "  467 


468  OBSTETRICS 

Diseases  of  the  Cervix. — Eiidocervicitis. — Gonorrhceal  infection  of  the 
cervical  canal  is  frequently  observed  during  pregnancy,  the  most  prominent 
symptom  being  a  profuse  and  persistent  leucorrhcea.  The  treatment  has 
already  been  considered. 

Carcinoma. — About  once  in  2,000  cases,  according  to  Sarwey,  pregnancy 
is  complicated  by  carcinoma  of  the  cervix.  It  is  most  common  in  women 
between  the  thirtieth  and  fortieth  years  of  life,  two  thirds  of  the  cases 
collected  by  SarTTSy  having  occurred  within  this  decade,  while  the  young- 
est patient  was  twenty-six  years  old. 

In  the  majority  of  instances,  the  condition  has  existed  before  concep- 
tion, but  may  make  its  appearance  during  pregnancy.  A  bloody,  f  oul-smell- 
ing  vaginal  .discharge  is  suggestive  of  malignant  disease,  but  unfortunately 
the  early'stages  are  often  unaccompanied  by  symptoms,  and  may  escape  de- 
tection unless  a  vaginal  examination  is  made  for  some  other  reason,  and  an 
indurated  and  excavated  ulceration  of  the  cervix  is  discovered. 

Pregnancy  tends  to  bring  about  rapid  growth  and  extension  of  a  pre- 
existing  carcinoma.  On  the  other  hand,  the  malignant  disease  influences 
pregnancy  very  unfavourably,  abortion  being  noted  in  30  to  40  per  cent  of 
the  cases.  It  likewise  predisposes  to  the  occurrence  of  placenta  preevia,  and 
at  the  time  of  labour  markedly  increases  the  risks  of  infection  or  spon- 
taneous rupture  of  the  uterus.  In  advanced  cases,  the  cervix  may  be  so 
indurated  by  carcinomatous  infiltration  that  dilatation  is  either  impossible, 
or  may  be  accompanied  by  profuse  haemorrhage.  In  603  cases  collected 
by  Sarwey,  the  mortality  at  the  time  of  labour,  or  during  the  puerperium, 
was  43.3  per  cent,  8  per  cent  of  the  patients  dying  undelivered. 

The  treatment  of  pregnancy  complicated  by  carcinoma  of  the  cervix 
differs  according  to  the  period  at  which  the  diagnosis  is  made  and  the  extent 
to  which  the  disease  has  progressed.  If  the  condition  is  detected  in  the  first 
half  of  pregnancy  and  the  process  has  not  extended  beyond  the  cervix, 
immediate  vaginal  hysterectomy  should  be  performed,  Sarwey  having  re- 
ported 26  such  operationswithout  a  death.  On  the  other  hand,  if  the  case 
is  inoperable,  gestation  should  be  allowed  to  continue  in  the  interests  of  the 
child.  ^^ 

In  the  second  half  of  pregnancy  the  choice  of  treatment  is  based  upon 
similar  indications,  except  that  the  large  size  of  the  uterus  materially  com- 
plicates vaginal  hysterectomy.  Hence,  if  a  radical  operation  appears  ad- 
visable, the  uterus  should  be  emptied  and  then  removed  through  the  vagina; 
or  a  laparotomy  may  be  performed  and  the  uterus  removed  unopened. 
In  inoperable  cases  pregnancy  should  be  allowed  to  go  on  to  term,  and 
then,  if  spontaneous  delivery  is  out  of  the  question,  Cesarean  section 
should  be  performed  in  the  interests  of  the  child.  For  particulars  con- 
cerning operative  treatment,  the  reader  is  referred  to  the  articles  of  Sar- 
wey and  Noble,  the  latter  having  collected  the  results  obtained  in  166  cases 
observed  between  the  years  1886  and  1896. 

Developmental  Abnormalities  of  the  Uterus. — Abnormalities  in  the  de- 
velopment m-  fnfijpjjjvP  one  or  both  Miillerian  ducts  may  result  in  malforma- 
tions which  sometimes  possess  an  obstetrical  significance.  Various  degrees 
of  malformation — from  an  almost  total  absence  of  the  uterus  on  the  one 


DEVELOPMENTAL   AUN'OHMALITIKS   OP   TIIH    UTERUS 


409 


hand  to  its  duplication  on  the  other  (uterus  didelphys) — are  encountered. 
The  accompanying  diagrams  (Figs.  42b'  to  431)  give  an  idea  of  the  nature 
of  tlic  more  important  varieties. 

Pregnancy  may  be  associated  with  any  one  of  these  malformations,  pro- 
vided an  ovum  be  cast  off  from  the  ovaries  and 
qo  serious  obstacle  be  opposed  to  the  upward  pas- 
sage of  the  spermatozoa  and  their  subsequent 
union  with  it. 

Pregnancy  in  the  Rudimentary  Horn  of  a 
Double  Uterus. — In  this  condition  the  course  of 
pregnancy  is  exposed  to  serious  modifications. 
We  owe  to  Mauriceau  the  first  description  of  a 
ease  of  this  character,  but  since  his  time  quite  a 
number  of  examples  have  been  reported. 

In  78  per  cent  of  the  84  cases  collected  from  the  literature  by  Kehrer 
in  1900,  the  proximal  end  of  the  rudimentary  horn  did  not  communicate 


Fig.  426. — Diagram  of  Uterus 
Unicornis  (Kehrer). 


Fig.  427. — Uteris  Pseudo-Didelphys 

(Kehrer  J. 


Fig.  428.— Uterus  Bicornis  Duplex 
(Kehrer). 


Fig.  429. — Uterus  Bicornis  Septus 
(Kehrer). 


Fig.  430. — Uterus  Bicornis  Subseptus 
(Kehrer). 


Uterus  Bicornis  Unicollis 
(Kehrer). 


.  431. 


Uterus  Bicornis  Unicollis  "with 
Rudimentary  Horn  (Kehrer). 


with  the  uterine  cavity,  so  that  in  them  pregnancy  must  have  followed  ex- 
ternal migration  of  the  spermatozoa  or  the  ovum.     In  the  former  class 


470 


OBSTETRICS 


of  cases  the  spermatozoa  pass  up  through  the  developed  horn,  gain  ac- 
cess to  the  pelvic  cavity,  and  then  fertilize  an  ovum,  either  on  the  sur- 
face of  the  opposite  ovary  or  within  the  tube  of  the  rudimentary  horn.  In 
the  latter  an  ovum  is  fertilized  in  the  neighbourhood  of  the  ovary  of  the 
normal  side,  and  is  then  carried  to  the  opposite  tube,  whence  it  gains  access 
to  the  rudimentary  horn,  in  which  it  undergoes  development. 

The  occurrence  of  pregnancy  in  a  rudimentary  horn  is  accompanied  by 
the  development  of  a  deciduaTn  the  non-pregnant  horn,  as  well  as  by  a 
marked  increase  in  its  size.  Unless  there  is  free  communication  between 
the  two  horns,  which  is  but  rarely  the  case,  a  pregnancy  in  this  situation 

*Bfc   . 


9$t 


Fig.  432. — Pregnancy  in  a  Kudimentary  Left  Uterine  Horn.     External  Migration 

or  Ovum  (Kelly; 
The  specimen  is  viewed  from  behind.  To  the  right  is  the  well-developed  uterus,  which,  after 
reaching  the  internal  os,  deviates  to  the  right  side.  Attached  to  the  cornu  is  the  right  tube, 
which  is  normal.  The  ovary  is  of  the  usual  size,  and  at  its  inner  and  lower  portion  is  the 
corpus  luteum  of  pregnancy.  Springing  from  the  left  side  of  the  uterus  at  the  internal  os  is 
a  muscular  band  ;  on  tracing  this  to  the  left  it  merges  into  the  rudimentary  uterine  horn.  On 
the  posterior  surface  of  this  horn  is  a  long  slit  representing  the  point  of  rupture.  Protruding 
through  the  rent  are  placental  remains.  The  left  tube  passes  off  from  the  outer  side  of  the 
rudimentary  horn.  The  left  ovary  is  flattened.  The  lines  on  the  well-developed  uterus  indi- 
cate the  size  of  the  uterine  cavity.  The  line  6,  c,  d,  e  indicates  the  course  of  the  left  Midler's 
duct.  Between  c  and  d  it  contains  a  lumen ;  where  it  is  represented  by  dotted  lines  it  consists 
of  a  solid  muscular  cord. 


is  a  very  serious  occurrence,  since  it  u_sually  eventuates  in  rupture,  which 
may  lead  to  the  death  of  the  patient  from  infra-peritoneal  haemorrhage. 
This  accident  usually  occurs  within  the  first  four  months,  and  was  noted 
in  87  and  47.8  per  cent  of  the  cases  collected  by  Sanger  and  Kehrer 
respectively,  in  1884  and  1900.  The  marked  difference  in  the  percentages 
is  attributable  to  greater  accuracy  in  diagnosis  and  more  frequent  recourse 
to  operative  interference,  since  the  appearance  of  Sanger's  work.    In  rare 


DEVELOPMENTAL  ABNORMALITIES  OF  THE  UTERUS     471 

-  pregnancy  may  go  <>n  t<>  term,  the  foetus  afterward  being  gradually 
eliminated  by  suppurativa  proee--*  -.  or  converted  into  a  Hilio-pa-dion. 

Rupture  is  always  attended  by  serious  intra-pcritoneal  h:eim>rrh:igc 
which  usually  ends  fatally  if  operative  procedures  arc  ma  undertaken,  82 
per  cenl  of  such  patients  in  Kehrer's  series  having  perished. 

The  existence  of  pregnancy  in  a  rudimentary  horn  can  occasionally  be 
recognised  during  the  early  months,  a  positive  diagnosis  having  been  made 
in  20  per  cent  of  Kchivr's  cases.  When  a  tumour  corresponding  in  size 
to  the  duration  of  pregnancy  tan  be  detected  alongside  of  what  appears 
to  be  the  slightly  enlarged  merits,  this  condition  should  always  be  thought 
of.  In  differentiating  it  from  a  tubal  pregnancy,  it  is  important  to  remem- 
ber that  in  the  former  the  round  ligament  is  felt  coming  off  from  the  distal 
side  of  the  tumour  instead  of  from  its  proximal  or  uterine  portion. 

Treatment. — If  the  condition  be  diagnosticated,  treatment  consists  in 
promptly  opening  the  abdomen  and  amputating  the  pregnant  horn.  This 
operation  was  first  performed  by  Sanger  m  in-4.  and  has  .since  been  re- 
peated on  44  occasions,  with  a  mortality  of  13.3  per  cent  (Kehrer  and 
Wells).  Too  frequently,  however,  the  first  suggestion  of  the  existence  of 
the  abnormality  is  afforded  by  the  symptoms  of  infra-peritoneal  haemor- 
rhage, and  an  operation  is  usually  undertaken  in  the  expectation  of  find- 
ing a  ruptured  extra-uterine  pregnancy. 

Pregnancy  in  Uterus  Unicornis. — Occasionally  only  one  horn  of  the 
uterus  is  developed'the  opposite  tube  and  ovary  being  lacking  or  arising 
from  the  lower  portion  of  the  uterus.  In  such  cases  pregnancy  usually 
pursues  an  uneventful  course,  and  the  condition  is  only  accidentally  recog- 
nised at  the  autopsy  table. 

Pregnancy  in  Uterus  Bicornis. — "When  the  two  horns  of  the  uterus  are 
well  developed,  but  no  connection  exists  between  them,  as  in  uterus 
didelphys,  or  when  they  are  partly  fused,  as  in  the  various  varieties 
of  uterus  bicornis,  pregnancy  may  occur  in  either  horn.  In  the  very 
rare  instances  in  which  a  twin  pregnancy  is  observed,  the  two  ova  mayv 
occupy  the  same  horn,  although  now  and  again  an  ovum  has  been  found  \ 
in  each.  ' 

TThen  pregnancy  occurs  in  one  horn  of  a  bicornuate  uterus,  the  other  un- 
dergoes s^mrpaTh~etic  h^ertrcyjohv  and  a  distinct  decidua  is  formed  in  its 
cavity.  Ordinarily  there  is  noninterference  with  the  course  of  pregnancy, 
and  spontaneous  labour  may  be  looked  for.  Much  more  rarely  the  non-\ 
pregnant  horn  may  partially  fill  up  the  pelvic  cavity  and  give  rise  to  serious  \ 
dystocia  similar  to  that  produced  by  tumours  of  other  origin.  Xagel  men- 
tions three  cases  in  which  labour  could  not  proceed  until  this  structure  had 
been  pushed  out  of  the  pelvic  canal.  In  two  other  instances — one  reported 
by  Lohlein  and  one  observed  in  the  Out-Patient  Department  of  the  Johns 
Hopkins  Hospital  and  reported  by  Bettman — the  non-pregnant  horn  ob- 
structed the  pelvic  cavity  and  gave  rise  to  rupture  of  the  uterus.  In  the 
latter  case,  the  condition  was  not  recognised  at  the  time  of  labour:  the  child 
presented  by  the  breech  and  was  extracted  with  considerable  difficulty.  The 
woman  died  thirty-six  hours  later  from  a  subperitoneal  hematoma  following 
an  incomplete  rupture  of  the  uterus,  which  was  clearly  due  to  impaction 


472  OBSTETRICS 

of  the  non-pregnant  horn  in  the  pelvis.  Werth  has  reported  a  case  in  which 
the  non-pregnant  horn  became  retroflexed. 

The  diagnosis  is  usually  not  made,  as  in  the  majority  of  cases  spon- 
taneous labour  occurs  at  term.  Our  own  patient  had  given'  birth  to  8  chil- 
dren without  any  suspicion  of  the  existence  of  the  deformity  having  arisen. 
Sometimes  the  existence  of  a  double  vagina  or  a  double  cervix  puts  one 
on  the  alert.  The  former  may  occur  with  a  normal  uterus,  whereas  the 
latter  condition  almost  invariably  indicates  the  existence  of  a  double,  or  at 
least  a  bicornuate,  uterus.  When  there  is  only  a  single  cervix,  as  in  uterus 
bicornis  unicollis,  the  condition  always  escapes  observation,  unless  the 
patient  is  subjected  to  examination  at  an  early  period  of  pregnancy,  and  the 
depression  noted  between  the  two  halves  of  the  uterus  gives  a  clew  to  the 
true  state  of  affairs. 

Displacements  of  the  Uterus. — Anteflexion. — Slight  degrees  of  ante- 
flexion are  frequently  observed  in  the  early  months  of  pregnancy,  but  are 
usually  without  significance.  In  the  later  months,  particularly  when  the 
pelvis  is  markedly  contracted  or  the  abdominal  wallsare  very  lax,  the  uterus 
may  fall  forward,  the  sagging  being  occasionally  so  marked  that  the  fundus 
lies  considerably  below  the  lower  margin  of  the  symphysis  pubis.  Even 
in  less  marked  instances  of  the  so-called  pendulous  abdomen,  the  patient 
may  complain  of  various  annoyances,  more  especially  of  exhaustion  on 
exertion  and  dragging  pains  in  the  back  and  lower  abdomen.  Marked  ame- 
lioration frequently  follows  the  wearing  of  a  properly  "fitting  abdominal 
supporter. 

Anteversion of  the  pregnant  uterus  is  occasionally  observed  in  patients 
who  have  previously  been  subjected  to  operative  procedures  for  the  relief 
of  symptoms  incident  to  retroflexion  of  the  uterus,  particularly  after 
vaginal  fixation,  less  frequently  after  an  improperly  performed  ventro- 
fixation, and  now  and  again  after  shprtening  of  the  round  ligaments.  The 
condition  is  accompanied  by  marked  discomfort  during  pregnancy,  and 
at  the  time  of  labour  may  give  rise  to  serious  dystocia,  which  will  be  con- 
sidered in  Chapter  XXXII. 

Betrodisplacement  of  the  Pregnant  Uterus. — Retroflexion  and  retro- 
version of  the  uterus  are  frequently  observed  in  non-pregnant  women,  and 
usually  cause  more  or  less  inconvenience,  though  occasionally  the  con- 
dition may  exist  for  years  without  any  abnormal  manifestation.  In  women 
who  have  never  borne  children,  inflammatory  or  other  changes  in  the  endo- 
metrium, resulting  from  circulatory  disturbances  incident  to  the  displace- 
ment, offer  a  serious  obstacle  to  the  occurrence  of  pregnancy.  In  parous 
women,  on  the  other  hand,  this  influence  is  less  pronounced,  but  preg- 
nancy, when  it  occurs,  is  prone  to  early  interruption,  retroflexion  being 
one  of  the  most  frequent  causes  of  spontaneous  abortion. 

In  the  vast  majority  of  cases  of  pregnancy  complicated  by  retrodisplace- 
ments,  the  uterus  was  already  out  of  place  before  conception;  although,  as 
has  been  pointed  out  by  Keitler  and  others,  the  abnormality  may  arise 
during  gestation. 

Pregnancy  is  more  frequently  complicated  by  retroflexion  than  by  retro- 
version, though  the  latter  usually  gives  rise  to  mnrp  ^prinns  symptoms.    In 


DISPLACEMENTS  OP  THE   UTERUS 


473 


i  hese  cases  several  cventualii  i<js  arc  possible:  the  displacement  may  undergo  t/ 
spontaneous  rcdmj_uia,  without  any  interruption  to  pregnancy;  abortion  ^» 
may  occur;  or,  if  neither  takes  place,  the  uterus  may  become  incarcerated^ 
in  the  pelvic  cavity  and  serious  consequences  follow.  ^J 

If  the  displaced  .uterus  is  not  adherent,  spontaneous  reduct  ion  usually 
occurs  during  the  second  or  third  month.    This  is  rendered  possible  by  an 
eccentric  hypertrophy  of  the  organ,  owing  to  which  the  anterior  wall  be-| 
comes  more  rapidly  distended  than  the  posterior,  and  emerging  above  the! 
superior  strait  eventually  draws  up~~Thc  rest   of  the  uterus.      After  the\ 
fundus  has  once  passed  the  promontory  of  the  sacrum  tliere  is  no  fear 
of  a  recurrence  of  the  condition.     Moreover,  spontaneous  reduction  is  not 
wholly  out  of  the  question,  even  when  adhesions  exist,  since  they  often  be- 
come stretched  and  occasionally  disappear  without  any  treatment.     Retro^, 
flexion  offers  better  prospects  than  retroversion;  indeed,  as  Duhrssen  and 
Keitler  have  pointed  out,  when  the  latter  condition  is  marked  spontaneous 
restitution  is  almost  impossible,  for  the  reason  that  the  cervix  rises  above 
the  symphysis  pubis,  while  the  fundus  is  held  back  by  the  promontory  of 
the  sacrum. 

In  a  certain  number  of  cases,  especially  when  the  fundus  is  firmly  ad- 
herent,  pregnancy  may  remain  uninterrupted  for  a  long  while.  This  pro- 
longation iTrendered  possible  by  the  marked  upward  growth  of  the  anterior 
wall  of  the  uterus,  while  the  posterior  wall  retains  its  original  situation 
and  forms  a  cavity  in 
which  one  pole  of 
the  foetus  is  retained. 
This  so-called  saccih- 
In  t  ion  of  the  uterus 
has  been  described 
in  detail  by  Oldham, 
Duhrssen,  and  others. 
Owing  to  the  abnor- 
mal position  of  the 
cervix  and  the  fact 
that  the  presenting 
part  lies  far  below  it, 
serious  difficulties  are 
to  be  expected  at  the 
time  of  labour,  which 
will  be  considered  in 
Chapter  XXXII. 

Abortion  is  com- 
mon in  pregnancies 
complicated  by  re- 
trodisplacements.  It 
usually  occurs  in  the 

course  of  the  third  month,  when  the  growing  uterus  pretty  well  fills  the 
pelvic  cavity  and,  becoming  irritated  by  the  pressure  to  which  it  is  sub- 
jected, begins  to  contract,  and  thus  brings  about  the  expulsion  of  the  ovum. 


Fig.  433. — Sacculation  of  Betroflexed  Pregnant  Uterus 
(Oldham). 


474 


OBSTETRICS 


In  other  cases  the  abortion  results  from  an  endometritis  which  may  have 
existed  before  the  onset  of  pregnancy,  or  have  been  produced  by  circulatory 
disturbances  incident  to  the  displacement.  This  termination  is  particularly 
likely  to  occur  when  the  sacrum  possesses  a  marked  vertical  concavity,  since 
the  projecting  promontory  opposes  a  serious  obstacle  to  spontaneous  resti- 
tution. 

If  pregnancy  continues  and  the  displacement  is  not  reduced  in  the  natu- 
ral course  of  events,  or  as  the  result  of  manipulations  on  the  part  of  the 
physician,  the  uterus  will  continue  to  increase  in  size  until  it  completely 
fills  the  pelvic  cavity  and,  being  unable  to  free  itself,  becomes  impacted,  and 
we  have  what  is  known  as  incarceration.  Untoward  effects,  due  to  pressure, 
come  on  sooner  in  retroversion  than  in  retroflexion,  for  the  reason  that  in 
the  former  the  cervix  compresses  the  lower  portion  of  the  bladder  at  an 
earlier  period.  Incarceration  is  accompanied  by  characteristic  symptoms, 
the  woman  complaining  of  pain  in  the  lower  portion  of  the  abdomen  and 
back,  and  disturbances  in  the  functions  of  the  urethra,  bladder,  and  rectum. 
Asthe  pelvis  becomes  more  and  more  filled  by  the  growing  uterus,  the  pres- 
sure upon  the  neck  of  the  bladder  and  urethra  becomes  so  intense  as  to 
.cause  retention  of  the  urine  with  consequent  overdistention.  When  the 
latter  has  reached  a  certain  limit,  the  overstretched  viscus  squeezes  out  a 
small  amount  of  urine  at  frequent  intervals,  but  never  empties  itself — 
■paradoxical  incontinence.     If  the  condition  is  not  soon  relieved,  the  symp- 


Fig.  434. — Incarceration  of  Ketroflexed  Pregnant  Uterus  (Swytzer). 


toms  become  more  intense,  cystitis  develops,  the  urine  becomes  bloody,  and 
eventually  gangrene  of  the  bladder  may  result,  necrotic  portions  of  its  lining 
membrane  being  cast  off  and  finally  expelled  through  the  urethra  with 
intense  cramp-like  pains.  In  other  cases  the  weakened  walls  of  the  bladder 
are  unable  to  withstand  the  distention  and  rupture  occurs,  followed  by  a 
fatal  peritonitis. 


DISPLACEMENTS  OF  THE    UTERUS  I  15 

.  Occasionally  the  uterus  may  undergo  inflammatory  changes  as  the  re- 
sult of  the  pressure  fco  which  ii  is  subjected,  and  become,  densely  adherent 
to  the  surrounding  parts,  while  mm  and  again  the  organ  may  be  forced 
down  and  out  of  the  pelvic  cavity  and  emerge  through  the  vulva  or  anus. 
In  sonic  cases  the  reel  inn  is  compressed  to  .such  an  extent  that  dcJWa- 
tion  becomes  impossible  and  gangrene  results,  [leus,  however,  lias  not  been 
observed. 

(iottschalk  found  that  the  following  were  the  most  frequent  causes  of 
death  in  671  cases  reported  in  the  literature  up  to  1894: 

Peritonitis  of  vesical  origin 17 

Uraemia 16 

Rupture  of  the  bladder 11 

Septicemia  of  vesical  origin 4 

Gangrene  of  the  bladder 3    " 

A  retrodisplacement  of  the  pregnant  uterus  should  always  be  sus- 
pected when  a  woman  in  the  early  months  of  pregnancy  complains  of  l.onff- 
continued.  frequent,  and  painful  micturition,  especially  if  there  is  a  his- 
tory of  antecedent  uterine  trouble.  Incontinence  of  urine  during  preg- 
nancy is  a  most  suggpstivp  sign  and  always  calls  for  a  thorough  vaginal 
examination.  With  the  bimanual  method,  the  soft  body  of  the  uterus  will 
be  found  occupying  the  pelvic  cavity,  while  the  cervix  is  forced  up  against 
the  symphysis  or  lies  above  it,  according  as  one  has  to  deal  with  a  retro- 
flexion or  retroversion.  It  should  be  remembered  that  a  pregnant  tube 
lying  behind  the  uterus  may  give  somewhat  similar  signs,  and  this  pos- 
sibility should  not  be  ruled  out  until  careful  examination  has  shown  thati 
the  slightly  enlarged  uterus  does  not  lie  in  front  of  the  soft  mass. 

Treatment. — If  the  condition  be  detected  in  the  first  three  months  of 
pregnancy,  bimanual  reposition  of  the  uterus  should_be_atteTu pted,  aided  by 
traction  upon  thp  cervix  hv  means  of  a  tenaculum  or  bullet  forceps.  After 
reposition  has  been  effected,  a  properly  fitting  Smith-Hodge  pessary  should 
be  introduced.  On  the  other  hand,  if  these  simple  manoeuvres  fail,  the 
patient  should  be  left  alone  until_  well  on  intojhe  thirfl_month,  in  the 
hope  that  spontaneous  reduction  will  still  occur.  If  this  has  not  taken  place 
by  that  time,  a  more  determined  effort  at  replacement  should  be  made,  with 
the  patient  in  the  knee-chest  position.  If  this  proves  unsuccessful,  reduc- 
tion can  usually  be  effected  by  bimanual  manipulations  under  anaesthesia. 

When  dense  adhesions  are  present,  various  procedures  have  been  recom- 
mended— the  forcible  breaking  up  of  the  adhesions  under  anaesthesia, 
attempts  to  loosen  tiiem  by  means  of  a  succession  of  vaginal  packs,  the 
colpeurynter,  or  the  "  watch-spring  "  pessary,  from  the  use  of  which  Sin- 
clair has  reported  excellent  results^ 

Generally  speaking,  these  methods  are  not  to  be  recommended,  and  if 
the  uterus  cannot  be  replaced  under  anaesthesia,  laparotomy  should  be  per- 
formed  and  the  adhesions  separated  under  the  guidance  of  the  eye,  as  recom- 
mended by  Mann  and  Fry.  In  one  of  my  cases  this  course  was  pursued  with 
most  satisfactory  results. 

On  the  other  hand,  if  symptoms  of  incarceration  supervene,  prompt 


476  OBSTETRICS 

treatment  is  imperative.  The  bladder  should  be  immediately  emptied. 
This  cannot  always  be  accomplished  with  the  ordinary  catheter  on  account 
of  the  elongation  of  the  urethra  and  neck  of  the  bladder  resulting  from 
the  displacement  (Fig.  434),  so  that  in  many  cases  the  male  instrument 
must  be  employed.  Its  introduction  may  often  be  facilitated  by  making 
traction  upon  the  cervix  with  a  tenaculum.  After  the  bladder  has  been 
emptied,  attempts  should  be  made  to  replace  the  uterus — under  anaesthe- 
sia, if  necessary.  But  if  this  cannot  be  effected,  most  authors  advise 
emptying  it  immediately,  either  bv  dilating  the  cervical_canal  or  by  punc- 
turing the  corpus  through  the  vaginal  vault.  At  present,  however,  I  be- 
lieve that  better  results  will  be  obtained  in  such  cases  by  laparotomy.  This 
operation,  however,  should  never  be  attempted  if  symptoms  of  infection 
or  gangrene  are  present,  since  the  weakened  and  necrotic  bladder  may 
be  injured,  or  dense  adhesions  may  be  encountered  which  have  formed  over 
the  uterus,  practically  shutting  it  off  from  the  abdominal  cavity  and  ren- 
dering the-  freeing  of  it  almost  impossible.  Under  these  circumstances  the 
obstetrician  should  content  himself  with  emptying  the  uterus  in  the  most 
conservative  manner  and  then  rely  upon  palliative  treatment. 

Lateral  Displacements  of  the  Pregnant  Uterus. — Slight  degrees  of  lateral 
displacement  of  the  uterus  during  pregnancy  are  relatively  frequent,  but 
usually  have  no  effect  upon  its  course  and  do  not  give  rise  to  symptoms. 
In  two  cases  reported  by  Lohlein  and  Gottschalk  the  uterus  had  under- 
gone a  considerable  degree  of  torsion,  its  left  margin  showing  marked  rota- 
tion towards  the  right,  which  in  the  second  case  was  associated  with  retro- 
flexion. 

Prolapse  of  the  Pregnant  Uterus. — Impregnation  in  a  totally  prolapsed 
uterus  is  very  rare  on  account  of  the  difficulties  attending  a  successful 
coitus,  but  if  the  prolapse  is  only  partial  it  is  comparatively  frequent.  In 
such  cases  the  cervix,  and  occasionally  a  portion  of  the  corpus,  may  protrude 
to  a  greater  or  lesser  extent  from  the  vulva  during  the  early  months,  but 
as  pregnancy  progresses  the  uterus  gradually  rises  up  in  the  pelvis,  and, 
as  soon  as  it  has  passed  beyond  the  superior  strait,  prolapse  is  no  longer 
possible.  On  the  other  hand,  if  it  retains  its  abnormal  position,  symp- 
toms of  incarceration  appear  during  the  third  or  fourth  month,  and  abortion 
is  the  inevitable  result,  there  being  no  cases  on  record  in  which  pregnancy 
^has  progressed  to  term  with  the  uterus  outside  of  the  body. 

If  there  is  a  tendency  towards  prolapse  during  pregnancy,  the  uterus 
should  be  replaced  and  held  in  position  by  a  suitable  pessary.  If,  however, 
the  pelvic  floor  be  too  relaxed  to  permit  its  retention,  the  patient  should  be 
kept  in  a  recumbent  position  as  far  as  possible  until  after  the  fourth  month. 
When  the  cervix  reaches  to  or  slightly  protrudes  from  the  vulva,  tne  great  - 
est  cleanliness  is  necessary,  as  several  cases  of  fatal  infection  have  been 
reported  as  occurring  even  without  any  internal  examination.  If  the  uterus 
lies  outside  of  the  vulva  and  cannot  be  replaced,  it  should  be  promptly 
emptied  of  its  contents. 

When  the  vaginal  outlet  is  markedly  relaxed,  the  congested  anterior  or 
posterior  vaginal  walls  not  infrequently  prolapse  during  pregnancy,  al- 
though the  uterus  may  still  retain  its  normal  position.    This  condition  may 


DISPLACEMENTS   OF   THE    UTERUS 


o-ive  rise  to  considerable  discomfort  ami  interfere  with  locomotion.  It  is 
not  amenable  to  treatmenl  until  after  delivery.  At  the  time  of  labour  these 
structures  may  be  forced 
down  in  iron t  of  the  pre- 
senting part  and  interfere 
with  its  descent.  When 
this  occurs  they  should 
be  carefully  cleansed  and 
pushed  back  over  it. 

In  pare  instances  a  her- 
nial protrusion  may  occur 
through  the  vagina,  the 
anterior  or  posterior  wall 
forming-  part  of  the  sac. 
Such  a  vaginal  enterocele 
may  form  a  tumour  ot  eoh- 
siderable  size  filled  with  in- 
testines. Hirst  has  col- 
lected 27  instances  from 
the  literature.  If  the  con- 
dition occurs  during  preg- 
nancy, the  protrusion 
should  he  replaced  and  the 
patient  kept  in  the  recum- 
bent position.  At  the  time 
of  labour  it  may  seriously 
interfere  with  the  advance 
of  the  head.  In  such  cases 
the  mass  should  be  pushed 
up  if  possible  and  when 
this     cannot     be     done     it 

should  be  held  out  of  the  way  as  well  as  may  be,  and  the  head  delivered 
past  it. 

H^pertropliicJEliinfiation  of  the  Cervix. — An  abnormally  elongated  cervix 
seriously  interferes  with  the  occurrence  of  conception,  but,  as  a  rule,  does 
not  complicate  the  course  of  pregnancy  or  labour.  The  canal  usually  be- 
comes shorter  and  more  dilatable  as  term  is  approached.  In  the  case  of 
a  patient  whom  I  saw  recently,  the  vaginal  portion  of  the  cervix  in  the  early 
months  was  5  centimetres  in  length  and  the  external  os  protruded  from 
the  vulva,  whereas  later  it  had  undergone  marked  softening  and  become 
reduced  to  normal  dimensions,  so  that  labour  occurred  spontaneously. 

Acute  (Edema  of  the  Cervix. — In  very  rare  instances,  and  usually  without 
apparent  cause,  the  cervix,  particularly  its  anterior  lip,  may  become  acutely 
cedematous  and  attain  such  proportions  as  to  protrude  from  the  vulva. 
This  condition  has  been  exhaustively  considered  by  Geyl  in  a  recent  publi- 
cation. 

Hernia.- — Pregnancy  occurring  in  women  suffering  from  inguinal  hernia 
is  not  influenced  bv  the  condition,  although,  owing  to  the  increased  intra- 


478 


OBSTETRICS 


abdominal  pressure,  the  previous  defect  may  become  aggravated.  Gener- 
ally speaking,  the  hernia  should  he  treated  palliatively  by  rest  and  the  use 
of  a  truss,  operative  treatment  being  deferred  until  after  delivery. 

Very  exceptionally,  the  uterus  may  form  part  of  the  contents  of  an 
inguinal  hernia,  and,  indeed,  several  cases  are  on  record  in  which  concep- 
tion has  occurred  under  such  circumstances.  Full  literature  upon  the  sub- 
ject will  be  found  in  the  articles  of  Adams  and  Eisenhart,  the  latter  having 
reported  a  case  in  which  one  horn  of  a  five-months'  pregnant  bicornuate 
uterus  occupied  the  right  inguinal  canal. 

Umbilical  liernice  are  frequently  noted  during  pregnancy,  but  are  usu- 
all  v '  without  eff  e  eF  up  on  the  condition.  During  the  early  months  the 
uterus  is  not  in  the  neighbourhood  of  the  hernial  opening,  while  later,  when 
the  fundus  reaches  its  level,  it  is  usually  too  large  to  gain  access  to  it.  In 
exceptional  cases,  however,  when  the  abdomen  is  markedly  pendulous,  such 
an  occurrence  is  not  beyond  the  range  of  possibility,  and  several  such  in- 
stances are  on  record.     Much  more  common  are  the  cases  in  which  the 

cicatrix  of  an  abdom- 
inal incision  yields  to 
the  increased  intra-ab- 
dominal pressure  inci- 
dent to  pregnancy, 
and  along  the  linea 
alba  is  formed  a  hernia 
into  which  the  preg- 
nant uterus  often 
makes  its  way,  being- 
then  covered  merely 
by  a  thin  layer  of 
skin,  fascia,  and  peri- 
tonaeum. 

A  similar  condi- 
tion is  occasionally  ob- 
served in  women  suf- 
fering from  marked 
diastasis  of  the  recti 
muscles.  Fig.  437  rep- 
resents a  patient  in 
whom  a  hernia  of  this 
kind  occurred  sudden- 
ly during  labour.  Or- 
dinarily, such  hernia? 
have  no  effect  upon 
pregnancy,  although 
they  may  add  marked- 
ly to  the  discomfort  of 
the  patient.  Temporary  relief  is  frequently  obtained  by  holding  the  uterus 
in  its  normal  position  by  a  properly  fitting  bandage.  At  the  time  of  labour, 
owing  to  the  loss  of  muscular  tone  in  the  abdominal  walls,  the  second 


436. — Pregnancy  in  Horn  of  Uterus  contained  in 
Inguinal  Canal  (Eisenhart). 


DISEASES   OF   THE    DECIDUA 


•17'.' 


is  liable  to  be  prolonged,  and  the  employment  of  forceps  is  i 
called  for. 


Fig.  437. — Heexi.v  of  Pregxaxt  Uteeus     Ada 


Diseases  of  the  Decidua. — In  non-pregnant  women  the  endometrium  is 
frequently  the  seat  of  lesions  which  are  grouped  together  clinically  under 
the  general  heading  of  endometritis.  Careful  histological  examination 
shows,  however,  that  the  term  is  usually  a  misnomer,  as  the  changes  are  Gen- 
erally trophic  rather  than  inflammatory  in  character.  The  most  important 
varieties  are: 

Hyperplastic  endometritis — general  hyperplasia,  localized  hyperplasia, 
polypoid  growths. 

Glandular  endometritis — glandular  hyperplasia . 

Interstitial  endometritis — general  hypoplasia. 

Acute  anxl  subacute  endometritis — inflammatory  changes. 

These  conditions  are  prototypes  of  more  or  less  similar  lesions  occur- 
ring in  the  decidua,  except,  of  course,  that  the  latter  are  modified  by  the 
histological  characteristics  incident  to  pregnancy. 

In  the  vast  majority  of  cases,  as  was  first  pointed  out  by  Teit.  the 
decidual  affection  represents  the  extension  of  a  lesion  already  existing  at 
the  time  of  pregnancy,  conception  occurring  in  a  uterus  affected  by  one 
of  the  various  forms  of  so-called  endometritis.  In  rare  cases,  however,  it 
may  be  primary. 

It  is  generally  believed  that  endometritis  is  almost  necessarily  associated 
with  sterility,  the  abnormal  secretion  of  the  uterine  glands  interfering 
with  impregnation,  and,  even  if  conception  occurs,  the  diseased  mucosa  does 
not  offer  a  favourable  nidus  for  the  implantation  of  the  ovum.     Certainly 


480 


OBSTETRICS 


this  belief  is  justified  in  any  marked  grade  of  the  affection,  and  every 
physician  can  recall  instances  in  which  the  patient  remained  sterile  until 
appropriate  treatment  had  restored  the  endometrium  to  its  normal  condi- 
tion. On  the  other  hand,  slight  degrees  of  endometritis  do  not,  as  a  rule, 
interfere  with  conception. 

Diffuse  Thickening  of  the  Decidua. — Hegar,  Kaltenbach,  Kaschewarowa, 
and  othersliave  described~lr  general  hyperplasia  of  the  decidua,  in  which 
the  membrane,  instead  of  becoming  thinner,  as  is  generally  the  case  after 
the  first  few  months,  assumes  unusual  proportions.  The  condition  fre- 
quently results  in  abortion,  as  a  large  part  of  the  nutritive  material 
intended  for  the  foetus   is   diverted   to   nourishing  the   decidua.      After 

abortion  or  labour,  a  thick- 

,  «  •  ened  decidua  may  cause  ab- 

-\    -/=       -    /'i*ryK  normalities  in  the  separation 

Localized  Thickening  of 
the  Decidua  (Decidua  poly- 
posa). — In  this  affection  the 
entire  decidua  is  somewhat 
thickened,  but  its  character- 
istic feature  consists  in  the 
projection  of  irregularly 
shaped,  knob -like  masses 
from  the  inner  surface.  Vir- 
chow  first  described  this  con- 
dition as  decidua  tuberosa  or 
polyposa,  and  considered  it 
to  be  syphilitic  in  origin, 
which,  however,  is  not  always 
the  case.  Ahlfeld  states  that 
it  is  frequently  observed, 
whereas  Bulius  holds  that  it 
occurs  but  rarely.  Personal- 
ly I  have  never  met  with  an 
instance. 

Glandular  Hyperplasia  of 
the  Decidua  {Endometritis  de- 
cidua glandularis).  —  Occa- 
sionally marked  hyperplasia 
of  the  glandular  structures""of 
the  decidua  is  present,  and  is  usually  associated  with  persistence  of  the 
glandular  ducts.  This  affection  commonly  manifests  itself  by  a  profuse  se- 
cretion  of  clearfhirl.  which  may  dribble  away  as  rapidly  as  it  is  produced,  or 
be  retained  m  th"e~uterus  to  be  suddenly  discharged  in  large  quantities  at 
variable  intervals — /iy^?wxii^_ii23^a£w^  The  amount  of  fluid  expelled 
varies  considerably,  though  Ahlfeld  has  reported  a  case  in  which  it  ex- 
ceeded 500  cubic  centimetres  on  several  occasions.  This  condition  pre-# 
^eludes  the  fusion  of  the  decidua  vera  and  reflexa,  and  theoretically  thfi^ 


Fig.  438. — Decidua  Polyposa  (Bulius). 


DISEASES  OF  THE   DECIDUA  481 

set' ict ion  should  cease  during  the  third  or  fourth  month.  In  the  occasional 
instances,  however,  in  which  it  continues  throughout  pregnancy,  it  must  be 
assumed  thai  fusion  of  these  structures  has  failed  to  occur. 

During  the  last  few  years  considerable  discussion  has  arisen  concern- 
ing the  nature  of  hydrorrhcea  gravidarum.  Stoeckel,  Reifferscheid,  and 
others  believe  that  it  does  not 
result  from  changes  in  the  de- 
eidua,    but    is   simply   due    to 

,  premature  rupture  of  the  mem- 

I  branes  and  the  escape  of  the 
Liquor  amnii,  which  is  not  fol- 
lowed by  the  immediate  termi- 
nation of  pregnancy.  Van  der 
Hoeven  inclines  to  the  older 
view,  and  bases  his  belief  upon 
the  analysis  of  specimens  of 
the  fluid  expelled,  which  dif- 

n  p  j.i       t  ••    •  Fig.  439. — Endometritis  Decidua  Cystica  (Breus). 

fers  from  the  liquor  amnn  m 

having  a  lower  specific  gravity  and  in  not  containing  albuminous  mate- 
rials or  urinary  constituents. 

In  rare  cases  the  openings  of  the  uterine  glands  may  become  occluded, 
small  retention  cysts  being  formed  which  project  from  the  surface  of  the 
decidua,  giving  it  anodulated  appearance.  The  affection  has  been  described 
by  Hegar  and  Breus  as  en dom etritis  cystica. 

Atrophic  Endometritis  decidjm^-UiadeY  this  heading  Hegar,  Ahlfeld, 
and  others  have  described  a  disease  in  which  large  portions  of  the  decidua 
vera  and  serotina  undergo  atrophic  changes  similar  to  those  which  occur 
normally  in  theportions  corresponding  to  the  lateral  margins  of  the  uterus. i 
They  offer  no  suggestion  as  to  its  aetiology,  but  consider  that  it.  interferes  \ 
with  the  nutrition  of  the  ovum  and  is  a  frequent  cause  of  abortion. 

Acute  Endometritis  decidua. — Acute  inflammatory  lesions  of  the  de- 
cidua not  infrequently  follow  attempts  at  criminal  abortion,  though  now 
and  again  they  may  occur  without  such  a  history,  cases  having  been  re- 
ported by  Donat,  Emanuel  and  Wittkowsky,  and  others.  Reference  has 
already  been  made  to  the  lesions  of  the  endometrium  which  are  sometimes 
associated  with  the  acute  infectious  diseases. 

In  one  of  Emanuel's  two  cases  bacilli  were  obtained  in  pure  culture 
and  were  likewise  present  in  the  sections,  while  in  the  other  cultures  were 
not  made,  but  cocci  were  demonstrated  in  the  tissues.  In  one  instance  I 
was  able  to  demonstrate  the  presence  of  cocci  in  sections,  but  unfortunately 
failed  to  make  cultures  before  placing  the  specimens  in  the  hardening 
fluid.  These  observations  prove  beyond  doubt  the  bacterial  origin  of  the 
lesions,  and  it  is  probable  that  future  investigations  will  show  that  such 
conditions  are  not  uncommon. 

I  have  also  observed  several  cases  in  which  the  decidua  presented  the 
characteristic  features  of  acute  inflammation,  the  vera  and  serotina  being 
thickened  and  their  external  surface  covered  with  a  yellowish  purulent 
exudate.    Under  the  microscope  the  tissue  was  found  to  be  infiltrated  with 


482 


OBSTETRICS 


leucocytes,  and  presented  the  typical  picture  of  acute  inflammation,  with 
here  and  there  areas  of  necrosis.  More  commonly,  however,  the  changes 
are  less  marked,  and  only  a  few  leucocytes  are  seen  lying  between  the  de- 
cidual cells. 

Maslowsky  and  Neumann  have  been  able  to  demonstrate  the  presence  of 
gonococci  in  several  cases  of  acute  inflammation  of  the  decidua;   it   is 


jSL-«» 


■*"    il?  i  i 


<&-- 


Cf»          ««»-.                                                                            Tii'1 

-s»  @ 

)     ;#?«»   gs^,^  ,i||@                       ®     ,**»    . 

"S.  T^v  !\Kg  t\X^  ^v 

Fig.  440. — Decidual  Endometritis 

.     X  280. 

probable  that  such  conditions  are  not  uncommon,  and  would  serve  to  ex- 
plain the  origin  of  not  a  few  cases  of  abortion. 

The  various  forms  of  enxjjmiejritis  decidua  complicating  pregnancy  are 
the  most  important  factors  in  the  causation  of  spontaneous  aboxijon,  and 
the  existence  of  some  one  of  them  should:  be  suspected  whenever  the  patient 
complains  of  a  sensation  of  weight  in  the  lower  abdomen  associated  with  a 
slightly  blood-stained"  or  clirty  brownish  discharge,  particularly  when  there 
is  a  history  ofgonorrhceal  infection  or  repeated  abortions. 

It  is  permissible  to  assume-  thaFsuch  conditions,  particularly  the  hyper- 
plastic forms,  sometimes  seriously  interfere  with  the  mechanism  of  the 
third  stage  of  labour,  owing  to  the  abnormal  consistency  of  the  decidua  and 
the  consequent  difficulty  experienced  in  its  separation. 

Endometritis  is  not  amenable  to  treatment  during  pregnancy.  Should 
the  patient  presenT  tlie  "slightest  sign  of  its  existence  after  abortion  or 
childbirth,  appropriate  measures  should  at  once  be  instituted,  since  the 
condition  frequently  persists  to  a  slight  degree,  and  may  become  seriously 
aggravated  in  a  subsequent  pregnancy. 

Metritis. — Unless  it  results  from  infection,  metritis  is  a  very  rase  com- 
plication of  pregnancy,  and  when  it  exists  was  usually  present  before  con- 
ception. It  predisposes  to  abortion  and  is  not  amenable  to  treatment  dur- 
ing pregnancy. 

Peri-uterine  Inflammation. — When  pregnancy  occurs  in  women  suffer- 
ing from  peri-uterine  inflammation,  considerable  discomfort  may  result 
from  the  stretching  of  old  adhesions.     Not  uncommonly  abortion  results. 


LITERATURE  483 

Now  and  again  the  inflammatory  changes  undergo  exacerbation  during 
pregnancy,  and  may  eventuate  in  abscess  formation,  which  is  accompanied 
by  the  usual  symptoms  of  pelvic  peritonitis.  Very  exceptionally  rupture 
may  occur  and  give  rise  to  acute  peritonitis,  which  usually  ends  fatally 
unless  appropriate  operative  measures  are  promptly  undertaken. 

Pregnancy  complicated  by  Tumours. — Pregnancy  is  occasionally  compli- 
cated by  the  presence  of  ovarian  or  uterine  tumours.  Although,  as  a  rule, 
they  do  not  materially  affect  its  course,  they  frequently  offer  a  marked 
obstacle  to  labour,  and  will  therefore  be  considered  in  detail  in  Chapter 
KXXII. 


LITERATURE 

Adams.     Hernia  of  the  Pregnant  Uterus.     Amer.  Jour.  Obst.,  1889,  xxii.  225-246. 
Ahlfeld.    Ueber  Endometritis  decidualis  tuberoso-polyposa.    Archiv  f.  Gyn..  1876.  x, 

168-176. 
Hydrorrhoea  gravidarum.     Endometritis  atrophicans.     Lehrbuch  tier  Geb.,  II.  Anfl., 

1898,  253. 
Bettman.     A  Case  of  Labour  in  a  Bicornuate  Uterus.     Johns  Hopkins  Hosp.  Bulletin, 

1902.  xiii.  57. 
Breus.    Ueber  cystose  Degeneration  der  Deeidua  vera.    Archiv  f.  Gyn..  1882.  xix,  483-489. 
Bulius.     Ueber  Endometritis  deeidua  polyposa  et  tuberosa.     Miinchener  med.  Wochen- 

schr.,  1896.  Nr.  28. 
Donat.     Endometritis  purulenta  in  der  Schwangerschaft.     Archiv  f.  Gyn.,  1884.  xxiv, 

4S1-486. 
Duhkssen.     Aussackungen,  etc.,  der  schwangeren  Gebarmutter.     Archiv  f.  Gyn.,  1899, 

lvii.  70-223. 
Eisenhart.     Fall   von   Hernia  inguinalis  comu  dextri  uteri  gravidi.     Archiv  f.  Gyn., 

1885,  xxvi,  439-459. 
Emanuel.     Zur  Lehre  von  der  Endometritis  in  der  Schwangerschaft.     Zeitsehr.  f.  Geb. 

u.  Gyn..  1895.  xxxi.  187-198. 
Emanuel  und  Wittkowsky.     Ueber  Endometritis  in  der  Graviditat.     Zeitsehr.  f.  Geb.  u. 

Gyn.,  1895,  xxxii,  98-111. 
Fry.     Cceliotomy  in  the  Treatment  of  the  Incarcerated  Pregnant  Uterus  when  Irreduci- 
ble.    Amer.  Gyn.  and  Obst,  Jour.,  1899.  xiv.  25-27. 
Geyl.     Zum  (Edema  acutum  cervicis  uteri  gravidi,  etc.     Volkmann's  Sammlung  klin. 

Vortrage,  X.  F..  1895,  Xr.  128. 
Gottschalk.     Zur  Lehre  von  der  Retroversio  uteri  gravidi.     Archiv  f.  Gyn.,  1894.  xlvi, 

358-383. 
Hegar.     Kysten-bildung  in  der  Deeidua.     Monatssehr.  f.  Geburtsk.,  1863.  xxi,  Supple- 
ment-Heft. 11. 
Die  Drusen  der  Deeidua  und  die  Hydrorrhoea  gravidarum,     Monatssehr.  f.  Geburtsk., 

1863,  xxii.  429-451. 
Hegar  und  Maiee.     Beitragezur  PathologiedesEies.    Virehow's  Archiv.  1871.  Hi.  161-192. 
Hirst.    Vaginal  Enterocele  in  Pregnancy  and  Labour.     Trans.  Amer.  Gyn.  Soc,  1893, 

xviii.  351-357. 
Kaltenbach.     Diffuse  Hyperplasie  der  Deeidua  am  Ende  der  Graviditat.     Zeitsehr.  f. 

Geb.  u.  Gyn..  1878,  ii.  225-231. 
Kaschewarowa.     Ueber  die  Endometritis  decidualis  chronica.     Vircbow's  Archiv,  1868, 

xliv.  103-113. 
Kehrer.     Das  Xebenhorn  des  doppelten  Uterus.     Heidelberg,  1900. 

39! 


484  OBSTETRICS 

Keitler.     Ein  Beitrag  zur  Retroflexion  und  Retroversion  der  schwangeren  Gebarmutter. 

Monatsschr.  f.  Geb.  u.  Gyn.,  1901,  xiii,  285-305. 
Lindenthal.     Aetiologie  der  Kolpohyperplasia  cystica.     Wiener  med.  Wochenschr.,  1897, 

Nrs.  1-2. 
Lohlein.     Ueber  Achsendrehung  des  Uterus,  besonders  des  graviden  Uterus.     Deutsche 

rned.  Wochenschr.,  1897,  Nr.  14. 
Mann.     The  Surgical  Treatment  of  Irreducible  Retroflexion  of  the  Gravid  Uterus.    Trans. 

Amer.  Gyn.  Soc,  1898,  xxiii,  135-140. 
Maslowsky.     See  Chapter  XXV. 
Mauriceau.     Histoire  d'une  femrne,  etc.     Traite  des  maladies  des  femmes  grosses,  6me 

ed.,  1721,  T.  I.,  86-91. 
Nagel.    Entwickelungsfehler  des  Uterus  und  der  Scheide.     Veit's  Handbuch  der  Gyn., 

1897,  i,  563-604. 
Neumann.     See  Chapter  XXV. 
Noble.     One  Hundred  and  Sixty-six  Cases  of  Cancer  of  the  Pregnant  Uterus,  etc.    Amer. 

Jour.  Obst.,  1896,  xxxiii,  873-882. 
Oldham.     Case  of  Retroflexion  of  the  Gravid  Uterus,  etc.     Trans.  London  Obst.  Soc, 

1860,  i,  317-322. 
Reifferscheid.     Beitrag  zur  Lehre  von  der  Hydrorrhoea  uteri  gravidi.     Centralbl.  f. 

Gyn.,  1901,  1143-1145. 
Sanger.     Ueber  Schwangersehaft  im  rudimentaren  Nebenhorn  bei  Uterus  duplex.     Cen- 
tralbl. f.  Gyn.,  1883,  324. 
Sarwey.     Carcinom  u.  Schwangersehaft.     Veit's  Handbuch  der  Gyn.,  1899,  iii,  2te  Halfte, 

lste  Abth.,  489-532. 
Sinclair.     A  Contribution  to  the  Diagnosis  and  Treatment  of  Retro-flexio-versio  Uteri 

Gravidi.     Trans.  London  Obst.  Soc,  1900,  xlii,  338-355. 
Stoeckel.     Beitrag  zur  Lehre  von  der  Hydrorrhoea  uteri  gravidi.     Centralbl.  f.  Gyn., 

1899,  1353-1361. 
Van  der  Hoeven.     Hydrorrhoea  gravidarum.     Monatsschr.  f.  Geb.  u.  Gyn.,  1899,  x, 

329-337. 
Veit.     Ueber    Endometritis    decidua.       Volkmann's   Sammlung    klin.   Vortrage,    1885, 

Nr.  254. 
Allgemeines  fiber  die  Aetiologie  der  Endometritis  in  der  Graviditat,     Zeitschr.  f.  Geb. 

u.  Gyn.,  1895,  xxxii,  111-116. 
Virchow.    Endometritis  decidua  tuberosa.    Die  krankhafte  Geschwulste,  1864,  ii,  478-481. 
Wells.     The  Clinical  Significance  of  Developmental  Duplications  of  the  Uterus  and 

Vagina.     Amer.  Jour.  Obst.,  1900,  xli,  317-365. 
Werth.     Retention  einer  Ausgetragenen   Frucht  in  dem  unvollkommen  entwickelten 

Home  eines  Uterus  bicornis.     Archiv  f.  Gyn.,  1881,  xvii,  281-297. 
Winckel.     Ueber  die  Cysten  der  Scheide,  etc.     Archiv  f.  Gyn.,  1871,  ii,  383-413. 


CHAPTEE  XXVIII 
DISEASES  AND  ABNORMALITIES  OF  THE  OVUM 


Any  portion  of  the  ovum — chorion,  amnion,  pUi^cnja.  or  JgeJ^is — may 
be  the  seat  of  disease,  or  may  presentabnormalities.  In  many  instances  the 
morbid,  process  is  limited  to  a  single  portion,  while  in  others  a  large  part, 
or  even  the  ovum  as  a  whole,  may  be  implicated.  Accordingly,  we  shall 
take  up  successively  those  lesions  or  abnormalities  which  are  limited  to 
the  chorion,  amnion,  or  placenta;  next,  those  in  which  the  entire  ovum,  and 
finally  those  in  which  the  foetus  alone  is  affected. 

Diseases  of  the  Chorion, — Hi/datidijjprm  21  oh. — In  this  condition,  also 
known  as  vesicular  mole,  cystic  degeneration  of  the  chorion,  or  myxoma 
elim'ii.  the  lev- 
minal  extremities 
of  the  chorionic 
villi  are  converted 
into  transparent 
vesicles  with  clear, 
viscid  contents. 
These  \avy  in  size 
from  minute  bod- 
ies a  few  milli- 
metres in  diame- 
ter to  cystic  struc- 
tures the  size  of 
hazel  -  nuts,  and 
hang  in  clusters 
from  the  villous 
stems,  to  which 
they  are  connect- 
ed by  thin  pedi- 
cles, giving  to  the 
external  surface  of 
the  chorion  a 
grape-like  appear- 
ance. The  formation  may  involve  the  entire  periphery  of  the  membrane, 
but  more  frequently  is  limited  to  portions  of  it. 

It  is  generally  stated  that  the  condition  was  first  described  by  Schenck 
von  Grafenberg  in  1565,  but  Kossmann  has  pointed  out  that  JEtius,  of 

485 


Fig.  441. — Hydatidifokii  Mole  (Bumm). 


486 


OBSTETRICS 


Amida,  in  the  early  part  of  the  sixth  century,  wrote  intelligently  about 
an  hydatidiform  mole,  although  he  had  no  clear  idea  of  its  nature. 

Owing  to  its  peculiar  appearance  and  the  fact  that  it  frequently  con- 
tained no  trace  of  a  foetus,  the  hydatidiform  mole  was  a  source  of  not  a  little 
speculation  to  the  early  writers  upon  medicine,  and  all  sorts  of  theories  were 
advanced  concerning  its  origin.  As  the  name  implies,  the  condition  was 
long  considered  to  he  analogous  to  the  hydatid  cysts  observed  in  other  parts 
of  the  body,  Goeze,  Percy,  and  others  believing  that  the  vesicles  contained 
worm-like  structures.  De  Graaf  held  that  the  vesicles  were  mature  ova, 
while  some  authors  thought  that  each  represented  an  early  pregnancy.     It 


**jy# 


!*•*«.*  Of™ 


s  v 

Fig.  442. — Section  or  Hydatidiform  Mole,  showing  Proliferation  of  Syncytium  and 

Langhans's  Cells.     X  75. 

£.,  syncytium  ;   V.,  normal  chorionic  villi ;  Z.,  Langhans's  cells. 


is  probable  that  many  of  the  extraordinary  cases  of  multiple  gestation  re- 
corded in  the  early  literature,  such  as  that  of  the  Countess  Hagenau,  who 
was  believed  to  have  given  birth  to  365  embryos  at  a  single  labour,  were 
really  instances  of  hydatidiform  mole. 

The  true  nature  of  the  affection  was  first  recognised  by  Velpeau  and 
Madame  Boivin  in  1827,  and  since  then  it  has  been  universally  admitted  to 
be  a  disease  of  the  chorion.  Numerous  theories  were  advanced  as  to  the 
nature  of  the  lesion,  until  Virchow  in  1853  stated  that  the  process  was 
essentially  a  myxomatous  degeneration  "of  the  connective  tissue  of  the 
chorionic  villi,  and  designated  it  as  myxoma  chorii.    This  view  obtained  im- 


HYDATIDIFORM    MOIJ-]  487 

mediate  acceptance  and  held  its  ground  until  IS!).">3  when  Man-hand  demon- 
strated thai  the  essential  feature  of  the  affection  was  to  be  Hound  nol  so 
much  in  (lie  struma  as  in  the  epithelial  covering  of  the  villi.  Se  showed 
that  both  the  syncytium  aimr~Langliaris?s  layer  ot  cells  underwent  profuse, 
and  irregular  proliferation,  penet rating  Nitabuch's  fibrin  layer  and  making 
their  way  into  the  depths  of  the  deeiduq.  and  not  infrequently  into  the 
uterine  musculature  as  well.  i  At  the  same  time  the  blood-vessels  of  the  ter-L 
minal  villi  disappeared,  and  the  stroma  dggengrated,  so  thai  in  advanced 
cases  its  nuclei  failed  to  take  up  the  usual  histological  stains  and  the  cells 
presented,  a  necrotic  appearance.  Moreover,  inasmuch  as  the  fluid,  contents 
of  the  vesicles  failed  to  give  the  characteristic  reaction  for  mucin,  Mar- 
chand  felt  justified  in  attributing  them  to  oedema. 

This  work  obtained  almost  immediate  acceptance,  and  was  promptly 
confirmed  by  many  investigators,  among  whom  Neumann,  Fraenkel,  Pick, 
Ouvry,  Schwab,  and  Van  der  Hoeven  may  be  mentioned.  Fig.  412  repre- 
sents a  section  through  the  most  recent  one  of  the  four  specimens  which  I 
have  examined,  all  of  which  abundantly  confirm  Marchand's  view. 

With  the  discovery  that  the  so-called  deciduoma  malianum  resulted  from 
a  malignant  proliferation  of  the  epithelial  elements  of  the  chorion,  and 
particularly  that  it  was  preceded  in  from  o.ne  third  to  one  half  of  the  record- 
ed cases  by  the  expulsion  of  an  hydatidiform  mole,  great  interest  arose 
as  to  the  nature  of  the  latter  condition  and  the  relation  which  it  bore  to 
the  production  of  the  former.  The  similarity  in  the  microscopic  structure 
of  the  two  pathological  processes  made  it  apparent  that  there  must  be  a 
genetic  relationship  between  them,  and  the  question  arose  whether  it  ex- 
isted in  all  cases. 

Neumann,  in  1897,  held  that  it  was  possible  to  differentiate  between 
two  forms  of  hydatidiform  mole — malignant  and  benign — one  of  which  \ 
was  and  the  other  was  not  followed  by  the  development  of  a  deciduoma  / 
malignum.    He  considered  that  in  the  former  the  proliferating  epithelium  \ 
invaded  the  stroma,  while  in  the  latter  it  was  limited  to  the  periphery  of  ^"l'a 
the  villus.    Pick  likewise  believes  that  there  are  two  forms  of  mole  which       — 
are  very  difficult  to  separate,  inasmuch  as  he  thinks  that  in  the  early  stages, 
at  least,  the  difference  is  biological  rather  than  histological.    On  the  other 
hand,  Van  der  Hoeven  believes  that  all  moles  are  essentially  malignant,  and 
that  the  development  of  a  deciduoma  depends  upon  the  completeness  with 
which  the  original  growth  has  been  expelled  from  the  uterus. 

Causation. — Virchow  and  Veit  agree  that  the  development  of  the  con- 
dition is  dependent  upon  endometritic  changes.  March  and  and  most  recent 
writers,  however,  hold  that  such  changes  are  secondary.  At  the  1901  meet- 
ing of  the  German  Gynaecological  Congress,  AicheL  stated  that  he  had  been 
able  to  produce  the  condition  experimentally  in  dogs  by  destroying  the  ves- 
sels going  to  the  clecidua,  and  thereby  interfering  with  the  nutrition  of 
the  chorionic  villi.  His  experiments  were  very  briefly  reported,  and  until 
satisfactory  and  conclusive  evidence  of  their  correctness  is  adduced  they 
should  be  received  with  caution.  On  the  other  hand,  it  is  not  unlikely  that  I 
in  many  cases,  at  least,  the  process  originates  primarily  in  the  ovum,  plausi-  > 
bility  being  lent  to  such  a  view  by  the  fact  that  in  rare  cases  of  twin  preg- 


J- 


^ 


488  OBSTETRICS 

nancy  one  ovum  may  be  perfectly  normal,  while  the  other  presents  the  lesion 
in  question.  It  is  hardly  probable,  if  the  endometrium  were  the  primary 
cause,  that  the  changes  would  be  limited  to  one  ovum.  A  characteristic 
case  of  this  kind  has  been  reported  by  Kahn-Benzinger. 

Clinical  History. — Hvdatkjiform  mole^is  a  rare  disease,  occurring,  ac- 
cording to  Madame  Boivin,  once  in  20,000  cases.  On  the  other  hand,  the 
recent  statistics  of  Williamson  would  indicate  that  it  may  be  found  about 
once  in  2,400  cases.  It  may  occur  at  any  period  of  reproductive  life,  but 
is  particularly  frequent  in  the  third  decade,  having  been  noted  between 
,  „  the  twentieth  and  thirtieth  years  in  41  and  38  per  cent  of  the  cases  col- 
^*^ected  by  Uorland  and  Kehrer  respectively.  It  likewise  appears  with  com- 
parative frequency  after  the  fortieth  year — in  16  and  22  per  cent  of  the 
cases,  according  to  the  same  author. 

The  process  usually  comes  on  earlv  in  pregnancy,  rarely  making  its 
appearance  after  the  third  month.  When  it  develops  comparatively  late  it 
does  not  implicate  the  entire  chorion;  but  whenever  a  considerable  portion 
of  the  membrane  is  involved,  atrophic  changes  affecting  the  foetus  are  con- 
stantly found,  and  the  development  of  the  latter  is  materially  influenced 
even  when  the  disease  is  relatively  mild  in  character.  In  the  former  class 
of  cases  the  foetus  dies  at  an  early  period,  and  often  undergoes  complete  dis- 
solution, all  trace  of  it  disappearing  excejDt  the  maternal  end  of  the  umbili- 
cal cord.  As  the  chorionic  villi  are  nourished  by  the  maternal  blood,  the 
condition  may  persist  after  the  death  of  the  foetus,  and  the  growth  attain 
considerable  proportions,  though  spontaneous  expulsion  usually  occurs 
^before  the  sixth  month. 

The  clinical  history  is  very  characteristic.  The  uterus  enlarges  much 
more  rapidly  than  usual,  so  that  the  fundus  is  often  found  at  the  level  of 
or  above  the  umbilicus  in  a  woman  who  gives  a  history  of  being  only  three 
or  four  months  pregnant.  After  a  longer  or  shorter  period  more  or  less 
profuse  haemorrhage  occurs,  which  persists  until  the  molejs^cast  off^  spon- 
taneously or  removed  by  the  physician. 

In  a  small  number  of  cases,  the  hypertrophic  villi  invade  the  uterine 
wall,  following  the  course  of  venous  channels.  This  happens  in  what  is 
known  as  the  destructive  mole,  characteristic  examples  of  which  have  been 
reported  by  Krieger,  Volkmann,  Jarotsky,  and  Waldeyer.  Xow  and  again 
the  growth  reaches  the  peritoneal  surface_of  the^uterus  and  gives  rise  to 
perforation,  followed  by  fatal  intra-peritoneal  haemorrhage.  This  compli- 
cation was  observed  by  Wilton,  Madame  Boivin,  Ouvry,  and  others. 

In  rare  instances,  at  varying  periods  after  the  expulsion  of  the  mole, 
smaJLpurplish  orjreddish  tumours  appear  in  the  vagina  or  about  the  vulva. 
On  microscopic  examination,  after  excision,  these  are  found  to  consist  for 
the  most  part  of  blood,  through  which  are  scattered  dropsical  villi  show- 
ing the  characteristic  epithelial  .changes.  In  a  number  of  cases  recorded 
the  uterus  was  perfectly  normal,  and  complete  excision  of  the  nodule  was 
followed  by  permanent  recovery.  The  question  has  accordingl}'-  arisen 
whether  such  tumours  represent  metastases  from  a  deciduoma  malignum  or 
a  malignant  hydatidiform  mole,  or  whether  they  are  merely  due  to  the 
accidental  transportation  of  particles  of  a  benign  growth.     Xeumann  and 


.  .  ■  j9iXA» 


.**■ 


DECIDUOMA   MALIGNUM  489 

Schmidt  take  the  former,  while  Pick  and  Schlagcnhausi-r  incline  to  the 
latter  view.  The  observations  of  Veit,  Poten,  and  myself,  concerning  the 
transportation  of  villi  in  normal  pregnancy,  lend  a  certain  probability  to 
the  latter  theory,  although  the  question  tnusi  remain  to  be  settled  by  future 
investigations  (see  Fig.  610). 

UjJp  fYrmi  ihn  p^jhi  1  ii v  of  the  development  of  a  dcciduoma  malig- 
num,. the  hydatidiform  mole  js_  a  serious  affection,,  since  Dorland  noted 
an  immediate  mortality  in  10  per  cent  of  the  100  instances  which  he  col-  „ 
lected  from  the  literature,  deaih  being  due  to  haemorrhage  at  the  time  of 


operation  in  3  per  cent,  to  perforation  of  the  uterus  in  2  per  cent,  and  to       p* ' 
infection  in  5  per  cent  of  the  cases.  £^f 

Dig  miosis. — Hydatidiform  mole  should  always  be  suspected  when  ha?m-  | 
orrhage  occurs  in  a  patient  whose  uterus  is  considerably  larger  than  it    a   ^__ 
should  be  for  the  duration  of  pregnancy,  though  in  not  a  few  eases  similar/ 
symptoms  are  noted  in  hydramnios.     A  positive  diagnosis  may  be  made 
when  one  finds  one  or  more  vesicles  in  the  uterine  discharges,  or  when  the  a  ■    + 

■mm  ■*  "*M|M  ^—— ^  -  |  —     ■"  ?  \  7 

finger  introduced  through  the  cervical  canal  is  able  to  palpate  the  charac-       -<-~ 
teristic  grape-like  masses. 

Treatment. — Owing  to  its  inherent  danger,  but  especially  to  the  pos- 
sible subsequent  development  of  a  deciduoma  malignum,  the  uterus  should 
be  emptied  as  soon  as  a  positive  diagnosis  is  made.  By  means  of  a  gauze 
pack  or  a  steel  dilator,  the  cervix  should  be  dilated  sufficiently  to  admit 
two  fingers,  with  which  the  growth  is  peeled  off  from  the  uterine  wall  and 
then  removed.  Care  should  be  taken  that  the  manipulations  are  made  as 
gently  as  possible  in  order  to  avoid  a  possible  perforation  of  the  uterus, 
whose  walls  are  likely  to  have  been  weakened  by  the  invasion  of  the  growth. 
After  removal  of  the  mole,  the  uterine  cavity  should  once  more  be  explored 
to  make  sure  that  it  is  thoroughly  empty. 

Every  woman  who  has  suffered  from  a  hydatidiform  mole  should  be  care- 
fully watched  for  the  next  few  months,  and  if  haemorrhage  makes  its  ap- 
pearance the  interior  of  the  uterus  should  be  palpated.  'Whenever  a  small 
nodular  growth  is  present  it  should  be  removed  and  subjected  to  microscopic 
examination:  and  if  the  characteristic  lesions  of  deciduoma  are  found  to 
be  present  immediate  hysterectomy  is  imperative,  in  the  hope  of  avoiding 
metastases.  On  the  other  hand,  as  has  already  been  pointed  out,  vaginal  or 
vulval  metastases  occasionally  occur  without  any  apparent  involvement  of 
the  uterus.  Under  such  circumstances  they  should  be  excised,  but  the 
uterus  left  in  place,  as  the  history  of  similar  cases  shows  that  the  majority 
of  the  patients  recover  permanently. 

Deciduoma  Malignum.  Chorionic  Epithelioma. — The  term  deciduoma 
malignum  was  applied  by  danger  to  a~"very  malignant  variety  of  uterine 
tumour  which  develops  after  a  full-term  labour,  abortion,  or  hydatidiform 
mole,  and  in  rare  instances  before  the  last  is  expelled  from  the  uterus. 
Strictly  speaking,  this  subject  should  be  considered  in  the  section  upon  the 
pathology  of  the  puerperium.  but  owing  to  the  frequent  genetic  relationship 
of  this  tumour  to  the  hydatidiform  mole,  it  is  best  considered  in  this  place. 

The  nature  of  the  growth  has  given  rise  to  a  great  deal  of  discussion, 
and  various  appellations  have  been  suggested  for  it,  the  most  important 


490  OBSTETRICS 

being  sarcoma  deciduo-cellulare,  chorio-epitlielioma,  syncytioma  malignum, 
and  carcinoma  syncytial  e. 

Sanger  read  his  first  paper  upon  the  subject  before  the  German  Gynae- 
cological Society  in  1892,  and  based  his  report  upon  the  following  case:  A 
woman,  twenty-three  years  of  age,  aborted  in  the  eighth  week  and  died 
seven  months  later.  At  autopsy  fourkrg^jsoft,  reddish,  spongy  tumours 
were  found  in  the  uterine  wall,  with  metastases  exhibiting  similar  charac- 
teristics in  the  lungs,  diaphragm,  tenth  rib,  and  right  iliac  fossa.  Micro- 
scopic examination  showed  that  the  tumour  was  made  up  in  great  part  of 
blood  spaces  bounded  by  large  cells,  which  Sanger  identified  as  decidual 
cells.  The  metastases  presented  a  similar  appearance  and  had  resulted  from 
the  transportation  of  tumour  masses  through  the  venous  channels.  As 
Sanger  believed  that  the  tumour  was  derived  from  decidual  cells  and  was 
therefore  of  connective-tissue  origin,  he  designated  it  decidual  sarcoma 
or  sarcorna  uteri  deciduo-cellulare.  The  appearance  of  his  monograph  in 
1893^  nTwhich  wasTcollected  all  that  was  then  known  upon  the  subject, 
created  profound  interest,  and  was  soon  followed  by  the  publication  of  many 
similar  cases. 

In  1895  I  published  a  monograph  upon  the  subject,  in  which  I  reported 
a  case  and  collected  24  others  from  the  literature.    My  patient  was  a  coloured 

woman  who  had  a 
f-*"V    ■•-..  t  spontaneous    full- 

,/.-_ ;  :>-a-^^      a.  fc^«  <%*»*^  _ ,.     J0. \      %itf>j,         term    labour.      A 

.-"-=*-:'  «  '•   :.  | ^ .,-:-*»  '■-  v' ...  A:  j&       <.,.■>      A  week  later  she  no- 

''*:' -•" ■■•'  £.    *'e*"  T/  y--A\-: .'-.. ;  ■\\£^rr?-   •;"'-5'%^i.V:i9"^     *  ticed  a  small  pam- 

::;.■  .:.-■?/"'*■•«.•  ■■■"•■  4^"®7.  ;,<r^v-.-^!»v  .' ."'-'■  ~-:i&# ' T  "'■'-%■.■  =,  ful    nodule    upon 

»-.*lp--:'^-  ■  •■■••■  '"'•  "  ': ' '''■'?  *  x'*  "VV  f»  ".--.,'.•  ^- ■•  ^^?.^*- ~~  '  the    right    labium 

!>":•?•  '"■' 'i>Vf--^- -?%g&  v^»*vT.'     *  tr*^?'---"- '■'■  j%3g--£}^  majus,  which  rap- 

'^j*  ""'  »,  . V^"'  "*  f>»-«  '■■^'^?>*^V^  "*^V/  ■}••••.  icily   increased    in 

'   ^***V*"a-:"    -"  •- ~~J     *^"*"*^^^^^^-iir4^  *^*^  s^ze'    so    tnat   two 

e^^^^.V./''^^;^^i',L"-"''"':^7;'^V  t% ■i^^'^' ^/^ r "  '      ;^^'-'l-:""  weeks  later  it  had 

^^^^S^^V^^i''^^^'"!  attained    the    size 

^*>'f#|SS¥       ::>V'fl^;*;tS^^^?  of     a     hen's,  egg 

:'  -^^^  y^:-'-^'^-j^'-i''^'''iKV''  **    i'  £'$~\l«°  *&%*'%■  and    resembled    a 

^J^v^v^''^"- '.'■  Vr',;A;>^,wW-^;r  haematoma  in  ap- 

&:    VV&V/lV'JW'^*'"''       "■'■     ••'--*'•■    "-■-"  pearanee.      Short- 

■7^^.*^J*;V^**T'^  -■■    :"  .^..,  ly  afterward  it  un- 

*     - '  -       :    •"r :■•.  ""  derwent     necrotic 

_  ^  .,  .  .  changes,      which 

Fig.  443. — Deciduoma   Maligxum,  showixg   Alveolae   Arrangement 

of  Pmmaht  Tdmo0e.    x  60.  were  accompanied 

by  a  profuse,  foul- 
smelling  discharge.  The  patient  gradually  grew  worse,  eventually  devel- 
oped a  cough  and  bloody  expectoration,  and  finally  died  six  months  after 
delivery.  The  nature  of  the  vulval  tumour  was  not  suspected  during  life, 
but  at  autopsy  the  lungs  were  found  to  be  studded  with  large  numbers  of 
metastases  of  varying  size,  which  resembled~pTacental  tissue  in  appearance. 
Similar  but  smaller  growths  were  present  in  the  kidneys,  spleen,  and  ovary, 
while  a  small  nodule  about  1  centimetre  in  diameter  was  found  in  the  uterus. 


DECIDUOMA    MALIGNUM 


r.»i 


Microscopic  examinal  ion  showed  that  the  uterine  growth  and  the  metas- 
tases, were  made  up  in  great  part  ot'jilrod  s parrs,  wln>«-  will  Is  were  formed 
by  lar.u'r  clear  rrlls  with  drlinitr  vesicular  nuclri.  At  the  margins  of  the 
primary  growth,  invading  the  ailjarrnt  musculature  were  Large  masses  of 
vacuolated  protoplasm  which  was  not  divided  into  individual  cells.     The 


■**$ 


1  !#'$*" 


..{"Wo-  »»  ** 


*^$W$^.     .s^x 


x 


- . .~-  -  -~  v  -  -  - 

Fig.  444. — Deciduoma  Maligntm,  showing  Syncytial  Masses  invading  a  Vbnods  Channel. 


nuclei  were  irregular  in  shape  and  stained  intensely.  Closer  examination 
showed  that  these  protoplasmic  masses  were  similar  to  and  idrntieal  in 
structure  with  the  syncytial  layer  of  the  chorionic  epithelium:  the  nature 
of  the  individual  cells  was  not  so  clear,  although  I  was  inclined  to  consider 
them  due  to  transverse  and  oblique  sections  through  the  syncytial  masses. 

The  same  year,  Marchand  wrote  a  most  important  monograph  upon  the 
subject.  He  identified  the  protoplasmic  masses  with  the_synoytium.  and 
the  individual  cells  with  those  of  Lanofhans'slaver.  Atthat  time  it  was 
generally  believed  that  the  former  was  of  maternal  and  the  latter  of  foetal 
origin,  so  that  according  to  this  view  the  tumour  would  be  composed  partly 
of  maternal  and  partly  of  foetal  tissue.  Later  investigations  indicated  that 
the  syncytium  was  also  of  fcetal  origin,  and  this  was  demonstrated  beyond 
peradventure  by  the  findings  in  Peters's  ovum.  Hence  it  follows  that  the 
tumours  in  question  are  entirely  fcetal  in  origin,  and  arise  from  tbe_jnn1ig- 
nant  proliferation  of  the  two  layers  ofehorionic  epithelium.  This  being 
the  case,  they  cannot  correctly  be  described  as  deciduomata  or  decidual  sar- 
comata, and  llarchand,  in  his  second  article  (1898),  proposed  the  term 


492  OBSTETRICS 

chorio-epithelioma.  In  view,  however,  of  the  multiplicity  of  designations, 
and  especially  the  fact  that  the  growth  was  so  described  by  Sanger,  it  ap- 
pears advisable  to  retain  the  term  deciduoma  malignum  for  clinical  pur- 
poses. 

Marchand's  conclusions  have  received  abundant  confirmation  at  the 
hands  of  all  who  have  studied  the  subject,  with  the  exception  of  Yeit  and 
certain  English  authorities.  Veit  holds  that  the  tumour  is  simply  a  sar- 
coma whose  cells  have  undergone  changes  in  appearance  under  the  influ- 
ence of  pregnancy.  Eden,  Kanthack,  and  other  English  observers  stated  be- 
fore the  London  Obstetrical  Society  in  1896  that  it  did  not  differ  materially 
from  other  sarcomata,  and  they  therefore  saw  no  reason  to  place  it  in  a 
class  by  itself. 

The  monographs  of  Sanger  and  Marchand  were  merely  the  beginning 
of  an  extensive  literature  upon  the  subject,  which  rapidly  increased  in 
volume  every  year.  Thus,  Dorland,  in  1897,  was  able  to  collect  52  cases, 
while  Marchand,  in  1898,  described  2  new  cases  and  mentioned  59  others, 
in  addition  to  those  recorded  in  his  first  monograph.  In  1902  Ladinski  was 
able  to  collect  132  cases. 

The  deciduoma  malignum  consists,  as  a  rule,  of  a  small  primary  growth 
which  gives  rise  to  abundant  meta.slkses.  particularly  in  the  lungs,  vagina, 
and  brain.  Thus,  in  the  52  cases  collected  by  Dorland,  metastases  were  ob- 
served in  the  lungs  of  78.38  per  cent,  in  the  vagina  of  54  per  cent,  and 
:  in  the  kidney,  spleen,  and  ovary  of  13.5  per  cent;  of  the  liver,  broad 
ligament,  and  pelvis  respectively  10.8  per  cent,  and  in  the  brain  5.4 
per  cent. 

The  vaginal  metastases  are  of  particular  significance,  and  in  several 
instances  growths  have  been  observed  in  the  vagina  without  the  discovery  of 
a  primary  focus  in  the  uterus.  Schmorl  has  even  reported  a  case  in  which 
generalized  metastases  developed  while  the  uterus  remained  perfectly  free. 
Under  such  circumstances  it  must  be  assumed  that  the  primary  growth 
originated  during  pregnancy  and  was  limited  to  the  placenta,  particles  of 

1  which  became  broken  off  and  were  carried  into  the  circulation,  giving  rise 
to  metastases  at  the  points  at  which  they  were  arrested,  while  the  primary 
tumour  itself  was  cast  off  with  the  after-birth.  Poten  and  Vassmer  have 
recently  reported  a  case  in  which  vaginal 'metastases  appeared  while  an 
hydatidiform  mole  was  still  in  the  uterus. 
^t  °-^  '  Clinical  History. — Deciduoma  malignum  may  occur  at  any  age  during 
the  childbearing  period,  and  always  follows  a  pregnancy,  whether  the  latter 
»**terminates  in  full-term  labour,  abortion,  or  hydatidiform  mole,  the  last  con- 
dition being  noted  in  nearly  50  per  cent  of  the  cases.  In  several  instances 
it  originated  from  an  extra-uterine  pregnancy. 

Ordinarily  there  is  no  suspicion  of  the  existence  of  the  growth  during 
pregnane}^  or  even  during  the  first  few  weeks  after  delivery.  In  a  small 
number  of  cases  haemorrhage  in  the  latter  part  of  the  puerperium  may  be 
the  first  indication"  of  its  existence,  though  this  symptom  is  usually  lacking. 
In  more  than  one  half  of  the  cases  the  first  indication  is  the  appearance  of 
vaginal  or  vulval  metastases.  These  are  usually  not  noted  until  some  weeks 
or  months  after  the  j)uerperium,  though  in  Poten  and  Vassmer's  case  they 


II  Yl>i:  AMNIOS  493 

appeared  before  the  extrusion  of  the  mole,  and  in  my  case  one  week  after  a 
full-term  labour.  The  development  of  metastases  m  the  Lunge  is  usually 
associated  with  pulmonary  symptoms,  cough,  and  bloody  expectoration, 
though  these  are  frequently  Lacking.  Unless  diagnosed  and  removed  by 
operative  procedures,  the  tumour  rapidly  causes  death,  the  majority  of 
patients  succumbing  within  t lie  lirst  year.  Indeed,  it  may  lie  said  that  this 
is  the  most  rapidly  fatal  malignant  growth  with  which  we  are  acquainted. 

Diagnosis. — In  a  considerable  number  of  eases,  the  diagnosis  is  not  made 
until  uterine  haemorrhage,  occurring  at  a  varying  period  after  the  puer- 
perium,  necessitates  curettage,  when  the  microscopic  examination  of  the 
scrapings  reveals  characteristic  changes.  In  other  instances,  as  has  already 
been  said,  the  occurrence  of  vaginal  metastases  is  the  first  indication  of  the 
existence  of  the  growth. 

The  possibility  of  its  development  should  always  be  borne  in  mind  when- 
ever a  woman  has  expelled  a  hydatidiform  mole,  and  the  appearance  of 
hemorrhage  or  of  other  more  obscure  symptoms  should  be  an  imperative 
indication  for  curettage  and  the  microscopic  examination  of  the  scrapings. 

Treatment. — If  curettage  reveals  the  existence  of  characteristic  lesions, 
immediate  hysterectomy  is  imperatiye.  On  the  other  hand,  when  vaginal 
metastases  are  present,  the  indications  for  this  operation  are  not  so  clearly 
marked,  as  we  know  that  in  many  such  cases  the  uterus  contains  no  growth. 
and  that  the  excision  of  the  yaginal  tumours  is  frequently  followed  by  com- 
plete recovery.  If  a  tumour  in  the  uterus  is  diagnosed,  hysterectomy  as  well 
as  excision  of  the  metastases  is  indicated,  though  the  chances  for  ultimate 
recovery  are  very  slight. ""Full  literature  upon  the  subject  will  be  found  in 
the  articles  of  Sanger,  Marchand,  Williams,  Teit,  Pierce,  Miinzer,  and 
Ladinski. 

Diffuse  Myxoma  of  the  Chorion. — Breslau  and  Eberth  have  called  atten- 
tion  to  a  rare  affection  of  the  chorionic  membrane,  in  which  its  connect- 
ive tissue  layer  undergoes  myxomatous  degeneration  and  becomes  converted 
into  a  jelly-like  "substance  analogous  to  the  TThartonian  jelly  of  the  cord. 
This  layer  may  attain  a  thickness  of  -i  to  5  millimetres,  but  does  not  appear 
to  exert  any  special  influence  upon  pregnancy. 

Myxoma  Fibrosum  of  the  Chorion. — Virchow  called  attention  to  the  fact 
that  a  greater  or  lesser  number  of  the  chorionic  villi,  which  enter  into  the 
formation  of  the  placenta,  may  lose  their  original  structure  and  take  part 
in  the  formation  of  a  tumour  made  up  of  dense  connective  tissue  with 
larger  or  smaller  areas  of  myxomatous  tissue  scattered  through  it.  As  the 
change  is  limited  to  the  placenta,  its  consideration  will  be  deferred  until 
the  tumours  of  that  structure  are  studied. 

Diseases  of  the  Amnion. — Hydramnios. — By  hydramnios  is  understood 
the  presence  of  an  excessive  quantity  of  liquor  amnii.  "Exactly  when  the 
proper  limit  is  passed  cannot  be  stated  with  accuracy,  for  the  reason  that 
the  authorities  do  not  agree  as  to  the  amount  to  be  considered  normal, 
Fehling  placing  it  at  680  and  Gassner  at  1,877  cubic  centimetres,  though, 
generally  speaking,  a  quantity  greater  than  2  litres  may  certainly  be  con- 
sidered excessive. 

Minor  degrees  of  hydramnios — 2  to  3  litres — are  common,  but  the  more 


494  OBSTETRICS 

marked  grades  are  of  infrequent  occurrence.  In  rare  cases  the  uterus  may 
contain  an  almost  incredible  amount  of  liquor  amnii,  Kiistner  having  ob- 
served 15  litres,  and  Schneider  3.0  litres  at  the  fifth  and  sixth  month  of 
pregnancy  respectively.  In  most  easels  the  increase  in  the  amount  of 
amniotic  fluid  is  quite  gradual,  but  exceptionally  it  takes  place  very  sud- 
denly, so  that  the  uterus  may  become  immensely  distended  within  a  few 
days — acu  te(_  liydramn  ios. 

The  fluid  in  a  case  of  hydramnios  is  usually  identical  in  appearance  and 
composition  with  that  which  is  normally  found  in  the  amniotic  cavity, 
although  Prochownick  states  that  the  former  occasionally  contains  a  slight- 
ly increased  amount  of  urea. 

JEtiology. — In  view  of  the  fact  that  there  is  still  considerable  discussion 
as  to  the  source  of  the  liquor  amnii  in  normal  pregnancy,  it  is  manifestly 
impossible  in  many  cases  to  give  a  satisfactory  explanation  for  its  excessive 
production.  As  was  said  when  the  physiology  of  the  foetus  was  dealt  with, 
it  must  be  assumed  that  the  amniotic  fluid  is  derived  in  great  part  from 
the  mother,  since  the  experiments  of  Schaller  appear  to  demonstrate  that 
the  foetal  kidneys  function  only  to  a  very  slight  extent,  if  at  all,  during 
intra-uterine  life.  At  the  same  time  it  is  not  a  priori  impossible  that 
foetal  urine  should  be  passed  into  the  amniotic  cavity  under  certain  patho- 
logical conditions. 

Generally  speaking,  writers  upon  hydramnios  state  that  the  excess  of 
amniotic  fluid  may  be  derived  from  several  sources — from  the  foetus,  from 
the  mother,  from  both  foetus  and  mother,  and  in  rare  cases  from  the  amnion 
itself. 

In  something  less  than  one  half  of  the  cases,  careful  examination  of 
the  foetus  after  death  reveals  the  presence  of  some  abnormality  which 
may  or  may  not  bear  a  causal  relation  to  the  disease.  Thus,  hydramnios  is 
sometimes,  although  not  always,  noted  when  the  foetus  presents  some  abnor- 
mality or  deformity,  particularly  hemjcephalus  or  spinaJ^ifid^L  Under  such 
circumstances  many  authors  believe  that  the  siiperalmnTlarrt,  fluid  is  the 
result  of  an  excessive  urinary  secretion,  which  is  brought  about  by  the 
stimulation  of  cerebral  or  spinal  centres  which  have  been  deprived  of  their 
usual  coverings,  just  as  happens  in  the  piqure  experiments  of  the  physiolo- 
gists. Hydramnios  is  also  found  associated  with  other  deformities,  such 
as  hare-lip,  the  various  varieties  of  club-foot,  ectopia  of  the  bladder,  etc.,  as 
well  as  certain  tumours  of  the  kidneys.     ' 

More  frequently,  however,  the  abnormality  which  is  supposed  to  give 
rise  to  hydramnios  is  to  be  found  in  lesions  which  cause  obstruction  to  the 
cjriailaiion  either  in  the  cord  or  within  the  foejrm-L  In  other  instances  the 
condition  is  attributed  to^renal  changes  or  to  abnormalities  in  the  cutaneous 
functions. 

Sallinger  has  shown  that  an  obstruction  to  the  circulation  in  the  um- 
bilical yein^is  accompanied  by  an  exudation  of  fluid  from  the  external  sur- 
face of  the  umbilical  cord  and  from  the  foetal  surface  of  the  placenta.  This 
he  attributed  to  the  persistence  of  the  so-called  vasa  pxaprja  of  Jungbluth, 
which,  springing  from  the  foetal  end  of  the  cord,  lie  between  the  chorion 
and  amnion  and  usually  become  obliterated  in  the  second  half  of  preg- 


BYDBAMNIOS  4'.'.". 

nancy.  Analogous  observations  have  been  made  by  Levison.  According  to 
Franque,  obliterative  changes  in  coats  of  the  arteries  of  the  chorionic  villi 
may  Lead  to  similar  results.  Leopold  and  Bar  have  shown  that  the  obstruc- 
tion may  be  due  to  stenosis  or  thrombosis  of  the  _mnliil''':|1  vt-j^i  while 
Fehling  has  attributed  it  to  torsion  of  the  cord 

More  frequently  the  obstruction  lies  within  tin-  t'o-ms.  Thus  Opitz  ob- 
served  cirrhotic  changes  in  the  Jivcr  in  all  of  hi-  cases.  Others  have  at- 
tributed  it  to  syphilitic  changes,  though  my  experience  leads  me  to  believe 
that  lues  is  an  unimportant  factor,  as  hydramnios  does  not  appear  to  occur 
much  more  frequently  in  syphilitic  than  in  normal  children.  In  a  consider- 
able proportion  of  cases  the  obstruction  to  circulation  is  due  to  cardiac 
nhnorma1itips_  Thus  Woerz  found  the  right  auricle  almost  entirely  oc: 
eluded  by  a  rhabdomyoma.  Bar  observed  tricuspid  insufficiency  and 
stenotic  changes  about  the  pulmonary  arteries;  Lebedeff,  aortic  stenosis, 
and  Nieberding  a  narrowing  of  the  ductus  Botalli. 

Many  authorities  believe  that  hydramnios  is  due  to  an  excessive  urinary 
secretion  resulting  from  renal  or  cardiac  lesions.  As  has  already  been 
pointed  out.  this  mode  of  origin  cannot  be  accepted  without  reservation, 
since  it  now  appears  fairly  certain  that  the  kidneys  normally  play  little  if 
any  part  in  the  production  of  the  liquor  amnii.  The  correctness  of  such  a 
view  is  now  and  again  forcibly  demonstrated  by  the  presence  of  certain 
abnormalities  in  the  urinary  tract  of  the  foetus.  Bissmann,  for  example,  has 
reported  a  case  in  which  a  fcetus  showing  complete  absence  of  both  kidneys 
was  born  alive  just  before  term,  thus  proving  that  the  renal  function  is  not 
necessary  to  intra-uterine  life,  and  that,  in  some  cases  at  least,  the  urine 
plays  no  part  in  the  production  of  the  amniotic  fluid. 

Opitz  thought  he  had  demonstrated  that  the  liquor  amnii  in  hydramnios 
contained  a  lvmphagogue  substance,  which  is  normally  absent.  He  con- 
sidered that  its  presence  in  the  tissues  of  the  fcetus  resulted  in  the  ex- 
traction from  the  intervillous  spaces  of  the  placenta  of  a  greater  amount 
of  fluid  than  usual.  This  necessitated  increased  exertion  on  the  part  of 
the  heart,  which  eventually  resulted  in  its  hvpertrophy.  As  a  consequence 
a  larger  amount  of  fluid  circulated  through  the  kidneys,  giving  rise  to  an 
increased  urinarv  secretion. 

It  is  generally  believed  that  the  ^etiological  importance  of  increased 
renal  activity  is  strikingly  illustrated  in  hydramnios  occurring  in  single- 
ovum  twins.  TTilson  (1899)  analyzed  the  histories  of  101  cases  of  hydram- 
nios, 51  of  which  occurred  in  single  and  the  remainder  in  multiple  preg- 
nancies— 16  twins  and  1  triplets.  Twenty-two  of  the  twins  were  uni-oval 
in  origin,  and  when  one  considers  that  these  are  much  less  frequently  ob- 
served than  double-ovum  twins,  it  is  apparent  that  something  connected 
with  the  former  must  exert  an  appreciable  influence  in  the  production  of 
the  disease.  In  such  cases,  as  a  rule,  the  excess  of  liquor  amnii  is  limited 
to  a  single  amnion,  while  the  other  contains  a  normal  or  diminished  amount 
of  fluid.  At  autopsy  the  heart  and  kidneys  of  the  foetus  suffering  from 
hydramnios  are  found  to  be  both  relatively  and  actually  larger  than  those 
of  the  normal  twin.  Wilson  attributed  this  difference  to  the  presence  in  the 
single  placenta  of  an  area  of  circulation  common  to  both  twins,  and  be- 


496  OBSTETRICS 

lieved  that  one,  for  some  reason,  received  a  larger  amount  of  blood  than  the 
other,  this  excess  giving  rise  to  cardiac  hypertrophy  which  still  further 
accentuated  the  condition,  and  in  turn  was  followed  by  renal  hypertrophy 
with  increased  secretion.  He  considered  that  the  primary  cause  for  the 
|  difference  in  the  amount  of  fluid  received  by  the  two  twins  was  to  be 
found  in  abnormalities  of  the  umbilical  cord,  by  which  the  flow  of  blood 
to  one  chilcTwas  rendered  mbre^lifncuTF,  as  in  the  cases  which  he  analyzed 
the  affected  twin  always  presented  some  abnormality  of  that  structure — 
velamentous  insertion,  excessive  length,  or  marked  narrowing. 

The  mode  of  production  of  hydramnios  in  such  cases  has  been  consid- 
ered in  detail  by  Schatz,  Werth,  and  Kiistner.  The  last-named  authority 
believes  that  the  cardiac  hypertrophy  comes  about  in  the  manner  already 
mentioned,  and  leads  to  a  still  further  increase  in  the  amount  of  circulating 
fluid.  Eventually  the  heart  becomes  unequal  to  its  task  and  insufficiency 
V  results,  which  is  followed  by  signs  of  obstruction,  particularly  in  the  liver, 
ithereby  completing  a  vicious  circle. 

Some  authors  consider  that  the  skin  plays  a  not  unimportant  part  in 
the  excessive  formation  of  liquor  amnii.  Budin  in  one  case  was  inclined  to 
attribute  it  to  a  large  nsevus,  through  which  he  believed  excessive  exudation 
occurred.  Furthermore,  Wilson  and  others  consider  that  excessive  cutane- 
ous activity  is  ofttimes  associated  with  cardiac  hypertrophy. 

In  a  small  number  of  cases  inflammatory  conditions  of  the  amnion  itself 
are  believed  to  play  a  part  in  the  production  of  the  condition,  leading  to 
increased  exudation  through  that  membrane. 

Occasionally  diseases  of  the  mother  which  are  attended  by  circulatory 
disturbances,  particularly  cardiac  and  renalaffections  and  visceral  syphilis, 
lead  to  oedema  of  the  placenta, "with  increased  transudation  into  the  amni- 
otic cavity.  One  or  other  of  the  conditions  just  mentioned  may  account  for 
the  excessive  production  of  amniotic  fluid  in  a  considerable  proportion  of  the 
cases;- but  at  the  same  time  they  do  not  always  afford  a  satisfactory  explana- 
tion, inasmuch  as  in  many  instances  careful  search  fails  to  reveal  the  pres- 
ence of  any  lesion  which  can  be  supposed  to  play  a  part  in  the  production 
/of  the  anomaly. 

^-  Symptoms^ — The  symptoms  accompanying  hydramnios  arise  from 
pjirelyjnechanical  causes,  and  are  due  to  the  pressure  exerted  by  the  over- 
distended  uterus  upon  adjacent  organs.  The  effects  are  particularly  marked 
in  the  respiratory  functions,  and  when  the  distention  is  excessive  the 
patient  may  suffer  from  severe  dyspnoea  and  cyanosis,  and  in  extreme  cases 
be  able  to  breathe  only  in  an  upright  posit  ion.  ("F~1"ema  often  occurs,  espe- 
cially in  the  lower  extremities  and  about  the  vulva. 

It  is  surprising  what  great  degrees  of  abdominal  distention  can  some- 
times be  borne  by  the  patient  with  comparatively  little  discomfort,  although 
this  is  the  case  only  when  the  accumulation  of  fluid  has  taken  place  gradu- 
ally. On  the  other  hand,  in  acute  hydramnios,  a  much  slighter  degree  of 
distention  may  lead  to  disturbances  sufficiently  serious  to  threaten  the  life 
of  the  patient. 

Diagnosis. — In  moderate  degrees  of  hydramnios,  palpation  and  jper^ 
cussion  enable  one  to  feel  confident  that  the  fluctuant  tumour  is  the  dis- 


BYDRAMNIOS 


41)7 


tended  uterus,  in  which  a  readily  ballottable  foetus  can  be  t'« ■  1 1 .  although  the 
hearl  sounds  are  heard  wTThT~d7Titc~ultv~ 

The  excessive  enlargemenl  of  the  abdomen  due  to  multiple  pregnancy 
occasionally  renders  the  differentiation  IVoni  hydramnios  almost  impos- 
sible; and,  moreover,  the  latter  is  a  frequeni  com  plication  of  the  former  con- 
dition.  Thus  it  appears  thai  the  bydramnios  is  usually  detected,  whereas  a 
multiple  pregnancy  associated  with  it  often  passes  unnoticed.  On  the  other 
hand,  in  a  multiple  pregnancy  not  complicated  by  hydramnios,  the  diag- 
nosis is  comparatively  easy,  inasmuch  as  the  uterus  offers  a  firm  consistence 
to  the  touch,  and  careful  palpation  will  reveal  the  presence  of  several  foetal 
poles  and  an  unusual  number  of  small  parts,  as  contrasted  with  a  marked 
iluctuation  and  the  difficulty  of  mapping  out  the  foetus  in  hydramnios. 

When  the  uterine  distention  is  excessive,  the  diagnosis  of  hydramnios 
becomes  even  more  difficult,  and  many  cases  are  recorded  in  which  the  con- 
dition was  mistaken  for  a  1  av^p_nya H a n_cy st oma ,  with  the  result  that  the 
contents  of  the  amniotic  cavity  were  evacuated  by  means  of  a  trocar,  or 
laparotomy  was  performed.  Inquiry  as  to  the  possibility  of  pregnancy, 
and  careful  examination  will  generally  serve  to  prevent  such  an  error. 

Excessive  abdominal  enlargement  due  to  ascites  can  usually  be  differen- 
tiated  by  the  characteristic  changes  in  percussion.  In  rare  instances  preg- 
nancy, complicated  by  a  large  ovarian  cystoma,  may  be  mistaken  for  hydram- 
nios. In  some  cases,  the  detection  of  two  tumours — one  corresponding  to 
the  uterus  and  the  other  to  the  cyst — will  permit  a  correct  diagnosis,  but  in 
others  the  condition  may  escape  detection  until  after  childbirth. 

Treatment. — Minorgrades  of  hydramnios  rarely  require  actiyp  tr-pnK. 
ment.  On  the  other~hand,  wITen  the  abdomen  is  immensely  distended  and 
respiration  is  seriously  hampered, 
the  termination  of  pregnancy  k 
urgently  indicated  no  matter  to 
what  period  it  may  have  advanced. 
In  such  cases  interference  is  the 
more  justifiable  since  experience 
teaches  that  spontaneous  prema- 
ture labour  frequently  occurs  if 
the  patient  is  left  alone,  and  the 
children  are  frequently  so  poorly 
developed  or  so  deformed  that 
their  chances  of  living  are  min- 
imal. 

In  such  cases,  the  symptoms 
can  be  promptly  relieved  by  per- 
forating the  membranes  through 
the  cervix,  after  which  the  amni- 
otic fluid  drains  off  and  labour 
pains  set  in.  YVhen  the  abdomen 
has  been  enormously  distended,  and  the  course  of  labour  particularly  rapid, 
there  is  an  increased  risk  of  atonic  haemorrhage  during  and  iust  after  the 
completion  of  the  third  staged    For  this  reason  the  uterus  should  be  care- 


Fig.  445. — Compression  i  if  FiETrs  ix  Oligo- 
hydramnios (Ahlfeld). 


498 


OBSTETRICS 


fully  watched  and  appropriate  treatment  instituted  at  the  slightest  sign  of 

danger. 

Oligo-liydr amnios. — In  rare  instances  the  amount  of  amniotic  fluid  may- 
fall  far  below  the  normal  limits,  and  occasionally  be  represented  by  only 

a   few   cubic   centimetres   of  clear,   viscid 
fluid. 

The  aetiology  is  even  less  well  under- 
stood than  that  of  hydramnios.  .laggard, 
in  1894,  reported  a  case  in  which  the  foetus 
presented  an  imperforate  urethra  with  ab- 
sence of  one  and  cystic  degeneration  of  the 
other  kidney,  and  he  therefore  concluded 
that  the  lack  of  amniotic  fluid  was  the  re- 
sult of  non-secretion  of  urine.  He  likewise 
collected  several  instances  from  the  litera- 
ture, in  which  the  anomaly  was  associated 
with  complete  absence  of  both  kidneys. 

Wlien  oligo-lrydramnios  occurs  early  in 
pregnancy  it  is  attended  by  serious  conse- 
quences to  the  foetus,  as  adhesions  may- 
be formed  between  its  exteriialsurface 
and  the  amnion  and  give  rise  to  serious 
deformities.  When  occurring  later,  its 
effect  upon  the  foetus,  though  less  marked, 
is  quite  characteristic  Under  such  cir- 
cumstances the  latter  is  subjected  to  pres- 
sure  from  all  sides  and  takes  on  a  peculiar 
appearance,  and  many  minor  deformities, 

such  as  club-foot,  are  frequently  observed  (Fig.  445). 

In  some  cases  of  oligo-hydramnios,  the  skin  of  the  foetus  is  markedly 

thickened,  and  presents  a  dry,  leathery  appearance.    Most  authorities  attrib- 
ute this  to  the  lack  of  amniotic  fluid,  but  Ahl- 

f  elcl  is  inclined  to  believe  that  it  is  the  cause  and 

not  the  result  of  the  condition,  since  the  skin 

lesion  may  be  so  marked  as  to  interfere  with  the 

normal  cutaneous  functions  and  thus  do  away 

with  one  of  the  sources  of  the  liquor  amnii. 
Amniotic  Adhesions. — In  oligo-hydramnios, 

and  occasionally  even  when  the  liquor  amnii  is 

present    in    normal    amounts,    adhesions    may 

form  between  the  amnion  and  the  surface  of 

the  foetus.    According  to  Simonart,  Chaussier, 

in  1812,  was  the  first  to  direct  attention  to  this 

condition,  and  its  consequences  were  further 

studied  by  Montgomery,   G.  Braun,  Kustner, 

Ahlfeld,  and  others. 

The  effects  of  amniotic  adhesions  are  variable  and  depend  in  great  meas- 
ure upon  their  location.    As  a  rule,  when  they  develop  early  in  pregnancy 


Fig.  446.— Encephalocele  result- 
ing from  Amniotic  Adhesions 
(Ahlfeld). 


Fig.  447. — Amputation  of  Fingers 
by  Amniotic  Adhesions  (Kust- 
ner)- 


AMNIOTIC   ADIIKSIONS 


499 


Fig.  448. — Asipttation  of  Arm  by 
Amniotic  Adhesions. 


tliov  give  rise  to  serious  deformities  of  the  -foetus.    The  following  abnormali- 
ties  have  been  directly  traced   to  the  condition:  Kncephalocele  or  hemi- 
cephalus:  fissure  of  the  face,  jaw,  or  lips;  fissure  of  Hip  thm'a.Y  ui<1'  ectopia 
cordis,  and  eventration  with  hernia  01  the  um- 
bilical cord. 

In  oilier  instances,  amniotic  bands  may 
encircle  an  extremity  of  the  foetus  and  so  com- 
press  ii  as  to  lead  to  strangulation  and  sub- 
sequent spontaneous  amputation.  Fig.  447 
represents  Lntra-uterine  amputation  of  the 
lingers,  ami  Pig.  1  IS  amputation  of  the  arms, 
produced  in  this  way.  Braun  lias  reported 
two  cases  in  which  the  death  of  the  foetus 
was  attributable  to  strangulation  of  the  um- 
bilical cord  by  such  bands. 

Inflammation  of  the  Amnion. — In  rare 
cases  inflammatory  processes  implicate  the 
amnion.  These  are  usually  associated  with 
similar  changes  in  the  chorion  and  decidua, 
and  result  from  attempts  at  criminal  abor- 
tion  or  from  the  extension  of  an  infection  that  has  originated  in  the 
decidua. 

Cysts  of  the  Amnion. — Xow  and  again  small  C3rstic  structures,  lined  by 
typical  epitneirum,  may  be  formed  in  the  amnion.  They  generally  result 
from  the  fusion  of  amniotic  folds  with  subsequent  retention  of  ffuid.  Spe- 
cial attention  has  been  devoted  to  this  subject  by  Ahlfeld.  The  same  ob- 
server has  also  described  a  dermoid  cyst  of  the  amnion,  which  does  not, 
however,  bear  critical  examination,  inasmuch  as  the  small  particles  found  in 
it  were  probably  mere  concretions. 

Abnormalities  and  Diseases  of  the  Placenta. — Abnormalities  in  Size, 
Shape,  and  Weight — The  normal  placenta  is  a  flattened,  roundish,  or  dis- 
coid organ,  which  averages  from  15 
to  20  centimetres  in  diameter,  and 
from  1.5  to  3  centimetres  in  thick- 
ness. It  is  relatively  larger  in  the 
(earlier  than  in  the  later  months  of 
^^%^^=£\)h7  '"        pregnancy,  and  varies  considerably 

^  J\#^  ^^s  '^"^flj^rfs^- J^-^        *n  ^Zt'  at  term-  though,  generally 

speaking,  the  thickness  is  in  in- 
verse proportion  to  its  area.     The 
placenta,  as  a  rule,  presents  more 
or  less  rounded  outlines,  but  now 
and   again   when   inserted   in   the 
neighbourhood  of  the  internal  os  it 
may  take  on  a  horseshoe-like  ap- 
pearance, its  two  branches  running  partially  around  the  orifice.     In  very 
rare  instances,  as  in  one  reported  by  Taurin,  it  may  be  a  broad  annular 
organ  which  encircles  the  uterine  cavity  just  as  in  carnivorous  animals. 
33 


Fig.  449. — Placenta  Fenestrata  (Hyrtl). 


500 


OBSTETRICS 


Fig.  450. — Placenta  Bipaetita. 


The  normal  full-term  placenta  on  an  average  weighs  about  one  sixth  as 
much  as  the  child — i.  e.,  somewhere  in  the  neighbourhood  of  _500^grammes. 
Exceptionally  it  may  be  considerably  heavier,  Levy  having  reported  a 
number  of  cases  in  which  it  exceeded  1,000  grammes  in  weight.  In  dis- 
eased conditions,  on  the 
other  hand,  this  proportion 
no  longer  holds  good,  and 
in  syphilis  the  placenta 
may  weigh  one  fourth,  one 
thirds  or  even  ong__half  as 
much  as  the^fietus.  In  al- 
buminuria it  also  under- 
«Jl|  goes  a  relative  increase  in 
weight,  due  almost  entirely 
to  the  imperfect  develop- 
ment of  the  foetus  which 
characterizes  such  condi- 
tions. The  largest  pla- 
centae with  which  we  are 
familiar  are  observed  in 
cases  of  general  dropsy  of  the  foetus  aud  placenta.  In  a  case  of  this  char- 
acter under  my  observation  the  weights  of  the  foetus  and  of  the  placenta 
were  1,140  and  1,200  grammes  respectively,  and  Cohen  has  reported  a  case 
in  which  the  latter  weighed  2,900  grammes. 

Multiple  Placenta  in  Single  Pregnancies. — Occasionally  in  a  single  preg- 
nancy the  placenta  is  divided  into  several  parts,  which  may  be  absolutely 
distinct  or  more  or  less  closely  united.  Such  abnormalities  have  been 
studied  more  particularly  by  Hyrtl  and  Eibemont-Dessaignes,  the  latter 
stating  that  they  occur  about  once  in  352  cases. 

In  rare  cases  the  placenta  may  be  oblong  in  shape  with  an  aperture  of 
varying  size  somewhere  in  the  neighbourhood  of  its  centre.  To  this  ab- 
normality Hyrtl  ap- 
plied the  term  j>la  - 
c  e  n  t  a_  f  enes  t  r  a  t  a . 
More  frequently  the 
organ  is  more  or  less 
completely  divided 
into  two  lobes. 
When  the  division 
is  incomplete,  and 
the  vessels  extend 
from  one  lobe  to  the 
other  before  uniting 
to  form  the  umbil- 
ical cord,  we  speak 
of  a  placenta  climidi- 

■ata  or  bipartita.    According  to  Ahlfeld,  this  anomaly  is  noted  about  once  in 
600  cases.    Again,  the  placenta  may  consist  of  two  separate  lobes,  the  vessels 


Fig.  451. — Placenta  Teipaetita  {Hyrtl). 


ABNORMALITIES  OF  THE   PLACENTA 


501 


Fig.  452. — Corrosion  Preparation  of  Placenta  Septu- 
plex  (Hyrtl). 


of  which  arc  perfectly  distinct  and  do  not  unite  until  just  before  entering 
the  cord— placenta  duplex  (see  Fig.  464).    Occasionally  the  organ  may  be 

made   up   of   three   distinct   lobes — placenta   triplex;    while    in   very   rare 
instances  it  may  consist  of  a. 
number  of  small  Lobes,  I  lyrtl 
!i,-i\  ing  described  as  many  as 
seven — placenta  septuples. 

All  of  these  conditions 
result  from  abnormalities  in 
ilie  Hood  supply  qfjthe  de- 
cidua.  (generally  speaEng, 
the  ""portion  of  the  ovum 
which  is  to  become  convert- 
ed into  the  chorion  frondo- 
sinii,  and  later  into  the  foetal 
portion  of  the  placenta,  is 
that  which  is  in  contact 
with  the  most  highly  vascu- 
larized portion  of  the  de- 
cidua.  If  the  vascularization,  instead  of  being  practically  limited  to  a  single 
area,  develops  in  several  separate  portions  of  the  decidua,  some  such  anomaly 
is  bound  to  occur.  Iviistner  believes  that  certain  cases  of  placenta  bipartita 
or  duplex  owe  their  origin  to  extensive  infarct  formation  by  which  the 

intervening  tissue  is  destroyed. 
Occasionally  this  is  undoubtedly 
true,  but  such  an  explanation 
cannot  be  accepted  when  the 
various  lobes  or  lobules  are 
separated  from  one  another  by 
apparently  normal  membranes. 
In  rare  instances  the  decidua 
reflexa  is  so  abundantly  supplied 
with  blood  that  the  chorion 
la?ve  in  contact  with  it  fails  to 
undergo  atrophy.  Under  such 
circumstances,  the  entire  pe- 
riphery of  the  ovum  is  covered 
by  functioning  villi,  so  that  the 
placenta,  instead  of  being  a  dis- 
coid organ  limited  to  the  de- 
cidua serotina,  corresponds  to 
the  entire  chorion  —  placenta 
^^^^^^^^^^^  membranacea.     This   abnormal- 

Fig.  453.— Placenta  Membranacea  (von  Weiss).         ity   does  not   interfere  with  the 

nutrition  of  the  ovum,  but  occa- 
sionally gives  rise  to  serious  complications  during  the  third  stage  of  labour, 
since  the  thinned-out  placenta  is  not  readily  separated  from  its  area  of 
attachment  and  is  retained,  manual  removal  becoming  necessary. 


502 


OBSTETRICS 


Fig.  454 — Placenta  Duplex,  with  Two  Succenturiate  Lobules. 
XX. 


An  important  and  not  infrequent  anomaly  is  the  s<>c&]}edj^a£enta  suc- 

centuriata,  in  which  one  or  more  small  accessory  lobules  are  developed  in 

the  membranes  at 
some  distance  from 
the  periphery  of  the 
main  placenta.  Or- 
dinarily they  are 
united  to  the  latter 
by  vascular  connec- 
tions. Occasional- 
]y,  however,  these 
are  lacking,  and  as 
a  result  we  have 
what  are  known  as 
placentce  spurice. 

The placenta 
succenturiata  is 
of  considerable  clin- 
ical importance,  be- 
cause the  accessory 
lobules  are  some- 
times retained  in 
the  uterus  after  the 
expulsion      of     the 

main   placenta,    and    may   give    rise    to    serious   haemorrhage.      For    this 

reason  one  should  always  bear  in  mind  the  possibility  of  their  existence, 

and  the   examination 

of    the    after-birth 

should  not  be  limited 

merely  to  the  inspec- 
tion of  the  placenta, 

but   shnrdfl    extend   to 

the    m  embranes    as 

well.      Should    small, 

roundish    defects    be 

present  in  the  latter 

a  short  distance  from 

the  placental  margin, 

the    retention    of     a 

succenturiate   lobe 

should   be    suspected. 

If,  in  such  cases,  the 

slightest     signs     of 

haemorrhage     occur, 

the    hand   should   be 

introduced    into    the 

uterus  for  the  purpose   of  locating  and  removing   the   offending  struc- 
ture. % 


Fig.  455. — Placenta  Makginata.     X  %■ 


INFARCTS  OF  THE   PLACENTA  503 

Placenta  marginafa  will  be  considered  when  wo  come  to  speak  of  infarcts 
of  the  placenta. 

hi  exceptional  instances  the  foetal  surface  of  the  placenta  may  present 
a  central  depression  surrounded  by  an  elevated  portion,  the  amnion  extend- 
ing from  the  edges  of  the  former.  This  condition  is  designated  as  placenta 
circumvallata,  and  is  due  to  a  proliferation  of  the  villi  at  the  margin  of 
?he~  placental  Iter  the  definite  attachment  of  the  amnion  has  occurred. 

Once  in  several  hundred  cases  the  placenta,  instead  of  being  inserted 
upon  the  lateral  walls  or  the  fundus  of  the  uterus,  is  implanted  upon  the 
lower  uterine  segment  in  such  a  manner  as  more  or  less  completely  to 
overlap  the  internal  os — placenta  pra'via.  As  this  condition  is  unavoidably 
associated  with  haemorrhage  during  the  first  stage  of  labour,  and  is  a  most 
serious  complication,  it  will  be  dealt  with  in  a  separate  chapter. 

Diseases  of  the  Placenta. — Infarct  Formation. — The  most  frequent  ab- 
normality of  the  placenta  consists  in  the  development  of  certain  degenera- 
tive changes,  which  have  been  variously  designated  as  schirrus,  atrophy, 
placentitis,  hepatization,  apoplexy,  phthisis,  fatty  and  fibro-fatty  degenera- 
tion of  the  placenta,  etc.,  but  which  are  most  appropriately  described  as 
placental  infarcts. 

These  structures  vary  materially  in  size,  shape,  and  appearance,  and 
are  best  described  under  the  following  headings : 

1.  .Small,  whitish  or  yellowish  fibrous  formations  occurring  upon  either 
the  fcetal  or  maternal  surface  of  the  placenta,  and  varying  in  size  from 
areas  hardly  visible  to  the  naked  eye  to  those  having  a  diameter  of  sev- 
eral centimetres.  These  rarely  attain  a  thickness  of  more  than  a  few 
millimetres,  and  are  sharply  differentiated  from  the  surrounding  placental 
tissue. 

2.  On  section  through  the  placenta  one  frequently  sees  wedge-shaped  or 
irregularly  round  areas,  which  are  usually  dull  white  in  colour  and  ex- 
hibit  a  striated,  fibrous  appearance.  They  present  a  striking  contrast  to 
the  surrounding  tissue,  which  appears  to  be  perfectly  normal. 

3.  Less  commonly,  considerable  portions  of  the  placenta  are  implicated 
in  the  process,  and  one  occasionally  finds  one  or  more  cotyledons  converted 
into  a  pale  white,  dense,  more  or  less  fibrous  area,  in  which  the  usual  spongy 
structure  of  the  placenta  is  lacking.  In  other  instances  a  large  portion  of 
the  organ  may  be  involved  in  the  change,  one  half  and  sometimes  nearly 
its  entire  substance  being  implicated. 

4.  Xot  infrequently  a  broad  rim  of  whitish  or  yellowish-white  material 
is  observed  extending  for  a  varying  distance  around  the  margin  of  the  foetal 
surface  of  the  placenta,  taking  in  a  larger  or  smaller  portion  of  its  periph- 
ery,  and  occasionally  forming  a  complete  ring  around  it.  These  bands 
vary  from  a  few  millimetres  to  3  or  -A  centimetres  in  breadth.  They  lie 
beneath  the  amnion  and  rarely  attain  a  thickness  of  more  than  a  few 
millimetres,  except  at  the  extreme  margin  of  the  placenta,  where  it  merges 
into  the  membranes.  This  condition  is  known  as  placenta  marginata.  Inl 
a  certain  number  of  cases  the  band,  instead  of  being  situated  at  the  margin  I 
of  the  placenta,  lies  somewhere  between  it  and  the  centre  of  the  organ, 
thus  forming  a  broad  zone  more  or  less  parallel  to  the  periphery,  but  sepa- 


504 


OBSTETRICS 


rated  from  it  by  apparently  normal  placental  tissue.  To  this  condition  the 
term  niarc/o  placentae  is  sometimes  applied. 

S.liirarer  instances  a  larger  or  smaller  portion  of  the  placenta  is  occu- 
pied by  a  pinkish  or  brickdust-coloured,  irregularly  shaped,  more  or  less 
solid  mass,  which  is  sharply  marked  off  from  the  surrounding  tissue.  Such 
masses  are  usually  most  prominent  on  the  maternal  surface  of  the  placenta, 
but  not  infrequently  extend  through  its  entire  thickness;  they  are  some- 
times termed  redviifarcts. 

Still  more  rarely,  scattered  through  the  substance  of  the  placenta,  are 
seen  roundish  areas  varying  from  bright  red  to  almost  black  in  colour,  and 
measuring  from  one  to  three  centimetres  in  diameter.  They  are  appar- 
ently composed  almost  entirely  of  blood,  and  are  sharply  differentiated  from 
the  surrounding  tissue  by  a  capsule  which  presents  a  more  or  less  fibrous 
appearance.  They  may  occur  singly  or  in  considerable  numbers,  so  that 
occasionally  the  entire  placenta  is  studded  with  them  and  presents  a  nodu- 
lar surface,  and  on  section  an  appearance  which  Pinard  has  aptly  described 
as  placenta  truffe. 

These  structures  are  also  designated  as  red  infarcts,  though  many  au- 
thors prefer  to  speak  of  apoplexy  or  hematoma  of  the  placenta.  They  differ 
markedly  in  structure  and  appearance  from  the  other  form  of  so-called  red 
infarcts,  and  probably  have  nothing  in  common  with  them. 

Frequency. — Minute  white  infarcts  are  to  be  found  in  every  placenta, 
while  similar  areas',  measuring  i  centimetre  or  more  in  diameter,  were  ob- 
served in  63  per  cent  of  500  consecutive  placenta;  which  I  examined.  If 
not  present  in  excessive  numbers,  they  possess  no  clinical  significance,  and 
according  to  the  researches  of  Eden  and  myself  are  to  be  regarded  as  signs 
of  senility  of  the  organ.  On  the  other  hand,  when  they  are  of  large  size  and 
abundant,  they  may  mechanically  throw  out  of  function  so  great  a  portion 
of  the  placenta  as  seriously  to  interfere  with  the  nutrition  of  the  foetus,  and 
sometimes  cause  its  death. 

Mode  of  Formation. — According  to  the  researches  of  Ackermann,  Orth, 
Eden,  Kermauner,  and  myself,  infarct  formation  is  the  ultimate  result  of 
obliterating  endarteritis  in  the  vejjSj^of^EnTrchorionic  villi,  and  is  brought 
about  in  tlie  following  manner:  As  soon  as  the  circulation  through  the  ar- 
teries of  the  chorionic  villi  is  interfered  with  by  the  endarteritic  process, 
Necrotic  changes  begin  to  appear  at  their  periphery  (Plate  XIV,  Fig.  2). 
pwing  to  the  fact  that  the  syncytium  is  in  direct  contact  with  the  maternal 
blood,  the  changes  occur  first  in  the  layer  of  tissue  just  beneath  it,  and  mani- 
fest themselves  as  coagulation  necrosis  of  Langhans's  layer  of  cells  or  the 
tissue  which  has  replaced  it.  As  the  process  becomes  more  marked  this  is 
gradually  converted  into  the  so-called  canalized  fibrin.  A  little  later  the 
syncytium  becomes  implicated  and  undergoes  a  similar  change,  the  fibrin 
then  coming  in  direct  contact  with  the  maternal  blood  in  the  intervillous 
spaces.  As  a  consequence,  the  blood  immediately  adjoining  the  necrotic 
tissue  coagulates  with  eventual  fibrin  formation. 

When  necrotic  changes  occur  simultaneously  in  several  adjacent  villi, 
the  maternal  blood  lying  between  them  undergoes  coagulation,  so  that  even- 
tually a  number  of  villi  become  fused  together  by  fibrin.     Still  further  . 


PLATE   XIV. 


Fie.  l. 


B. 


'•'V  -' ■  Ky-\  %f-     vi 


iff  5 '  ?& 


*.» 


^rvr-^-W^^ai 


CF. 


ill  \    ,     ^    <r  -x*  .       .,        -/-fg-.'     .    '., 


nd ■      **v ;  v  ■    ^  <^\t^L y^  -"  •  X-fry^ 

W*      .  1    \    *     ""•/in       :'      J.  .      t      «'t»»*  H-t^         WtivW 


-^.T^.T^.ft^'^-'^'- 


INFARCT  FOEMATION.      X  60. 

Fig.  1. — Fully  developed  infarct. 

Fia.  2.— Chorionic  villi,  showing  endarteritis  and  formation  of  canalized  fibrin.      J5,  blood  in  in- 
tervillous spaces ;    C.  F.,  canalized  fibrin ;  End.,  arteries  showing  obliterating  endarteritis. 


CYSTS   OF   THE    PLACENTA 


5(  15 


changes  then  occur  in  the  stroma  of  the  incarcerated  villi,  the  cells  undergo 
coagulation  necrosis,  and  finally  the  conversion  into  fibrin  becomes  so  ex- 
tensive that  large  areas  arc  produced  in  which  only  the  shadows  of  degener- 
ated villi  can  he  distinguished  (Plate  XIV,  Fig.  1).  Ultimately  the  outlines 
of  the  villi  disappear,  and  the  entire  mass  takes  on  a  homogeneous  fibrinous 
appearance,  in  which  ii  is  impossible  to  distinguish  the  component  parts. 
For  full  particulars  concerning  the  process  the  reader  is  referred  to  my 
monograph  upon  the  subject. 

Steffeck  and  many  recent  writers  are  inclined  to  attribute  the  starting- 
point  of  the  process  to  inflammatory  and  degenerative  changes  in  the 
deeidua.  It  would  seem,  however,  that  there  are  no  grounds  for  such  a  be- 
lief, and  that  their  conclusions  were  based  upon  faulty  premises,  in  that 
these  authors  considered  that  the  cells  making  up  the  so-called  decidual 
septa  were  of  maternal  instead  of  foetal  origin,  as  has  been  rendered  probable 
by  recent  investigations. 

Red  infarcts  of  the  placenta  are  less  frequently  observed.  In  some 
cases  they  are  associated  with  albuminuria  on  the  part  of  the  mother,  which 
was  present  in  33,  60,  and  67  per  cent  of  the  cases  collected  by  Cagny, 
Rossier,  and  Martin  respectively.  Unlike  white  infarcts,  they  possess  a  con- 
siderable  clinical  significance  and,  whenever  well  marked,  are  associated 
with  imperfect  development  of  the  foetus,  and  sometimes  cause  its  death. 
Unfortunately,  we  are  not  in  a  position  to  explain  satisfactorily  their  mode 
of  formation,  and  must  be  content  with  pointing  out  the  relation  wlncli  tney 
bear  to  albuminuria 
on  the  one  hand  and 
to  imperfect  develop- 
ment of  the  child  on 
the  other. 

Eed  infarcts  are 
not,  as  a  rule,  ob- 
served in  the  placenta 
of  eclamptic  women, 
being  noted  only  in 
those  cases  in  which 
the  onset  of  the  dis- 
ease has  been  pre- 
ceded by  distinct  and 
continued  nephritic 
disturbances. 

Cysts  of  the  Pla- 
centa.— Cystic  struc- 
tures are  frequently 
observed  upon  the 
foetal  surface  and  oc-  FlG.  456._ CrsT  0F  pLACExta  (Ehrendorfer).    xK- 

casionally     in     the' 

depths  of  the  placenta.  Small  cysts  a  few  millimetres  in  diameter  were 
noted  in  56  per  cent  of  the  cases  collected  by  Kermauner.  Larger  ones, 
occasionally  attaining  the  size  of  a  lemon,  are  observed  but  rarely. 


506  OBSTETRICS 

Cysts  projecting  from  the  foetal  surface  of  the  placenta  are  derived  from 
the  chorion,  as  is  shown  by  the  fact  that  the  amnion  can  be  readily  stripped 
off  from  them.  Their  contents  are  usually  clear  and  transparent,  but  are 
sometimes  bloody  or  grumous  in  character.  The  walls,  especially  the  por- 
tions adjacent  to  the  intervillous  spaces,  are  lined  in  great  part  by  a  dull 
whitish  membrane,  while  occasionally  a  portion  is  occupied  by  a  white 
infarct. 

On  microscopic  examination,  the  lining  membrane  is  found  to  be  made 
up  mainly  of  one  or  more  layers  of  tolerably  large  epithelial  cells  with 
J  round  vesicular  nuclei  which  frequently  present  various  degrees  of  de- 
/  generation.  Here  and  there,  corresponding  to  the  situation  of  a  white 
infarct,  the  cells  are  absent  and  the  wall  consists  of  fibrin.  The  researches 
of  Ehrendorf  er,  Peiser,  De  Jong,  and  Vassmer  have  clearly  shown  that  the 
cells  in  question  correspond  to  those  of  Langhans's  layer,  and  are  derived 
from  the  trophoblastic  tissue  which  forms  the  epithelial  covering  of  the 
chorionic  membrane,  and  that  the  cysts  result  from  their  degeneration. 

The  cysts  occurring  in  the  depths  of  the  placenta  rarely  exceed  1  centi- 

metre  in  diameter.     They  frequently  occupy  the  centre  of  an  infarct,  are 

filled  with  grumous  contents,  and  were  mistaken  by  the  older  writers  for 

abscesses.     In  other  cases  the  contents  are  clear.     Such  structures  may  be 

derived  in  one  of  two  ways:  either  by  the  softening  and  breaking  down  of 

an  infarct,  the  cyst-wall  then  consisting  of  fibrin,  or  from  the  degeneration 

of  the  trophoblastic  cells  which  make  up  most  of  the  so-called  decidual 

septa.     In  the  latter  case,  the  walls  are  composed  of  cells  identical  with 

those   observed   in   the   cysts   occurring   upon  the    foetal    surface    of   the 

placenta. 

n  So  far  as  present  experience  goes,  cystic  formations,  whether  occurring 

I    upon  the  foetal  surface  or  in  the  depths  of  the  placenta,  are  of  interest 

\  purely  from  a  pathological  point  of  view,  and  exert  little  or  no  influence 

1  upon  the  course  of  pregnancy  or  labour. 

Tumours  of  the  Placenta. — John  Clarke,  in  1798,  described  a  solid  tu- 
mour~a5oiLl  the  Hi'Ze  ol  a  man's  fist,  which  made  up  a  large  part  of  the 
placenta.  Since  then  a  number  of  similar  tumours  have  been  described, 
something  less  than  50  being  recorded.  Niebergall  and  Albert,  in  1897 
and  1898,  respectively,  were  able  to  collect  30  and  36  cases  from  the  litera- 
ture. Since  then  Gkieniot,  Osterloh,  and  Bode  and  Schmorl  have  described 
additional  instances. 

All  tumours  of  the  placenta  which  have  thus  far  been  studied  are  of 
connentive-tjssrip  nriOTn  The  most  frequent  variety  is  the  myxoma  fibro- 
sum  of  Virchow,  which  is  a  tumour  of  varying  size,  composed  in  great  part 
of  fibrous  tissue  having  abundant  oval  nuclei,  with  typical  myxomatous 
areas  scattered  through  it. 

The  36  tumours  collected  by  Albert  can  be  classified  as  follows: 

Myxoma  fibrosum 14 

Fibroma 10 

Angioma. 9 

Sarcoma 2 

Hyperplasia  of  chorionic  villi 1 


DISEASES   OF   THE    PLACENTA  507 

The  two  cases  of  sarcoma  were  described  by  Hyrt]  as  "placenta  in  pla- 
centa." Their  nature,  however,  is  open  to  considerable  doubt,  but  in  all 
probability  they  were  fibromata. 

We  are  absolutely  ignorant  as  to  the  aetiology  of  placental  tumours,  but 
it  is  interesting  to  note  that  several  have  originated  in  a  succenturiate  pla- 
centa, while  the  main  organ  remained  intact. 

According  to  Albert  they  exert  a  deleterious  influence  upon  the  course 
of  pregnancy  and  labour.  In  the  3G  cases  collected  by  him,  only  one  third 
of  the  children  were  born  alive  or  were  normal  in  size.  Premature  labour  , 
was  noted  in  13,  and  hydramnios  in  4  instances.  The  tumour  formation  ap- j 
peared  to  interfere  with  the  separation  of  the  placenta,  as  its  manual  re- 
moval was  necessary  in  3  cases,  while  haemorrhage  during  or  immediately 
after  the  third  stage  of  labour  occurred  5  times. 

Inflammation  of  the  Placenta. — Under  the  term  placentitis  many  of  the 
older  writers  described  changes  which  we  now  recognise  as  infarct  forma- 
tion Moreover,  as  has  already  been  said,  small  placental  cysts  filled  with 
grumous  contents  were  formerly  thought  to  be  abscesses.  Hence  it  follows 
that  most  of  the  statements  in  the  abundant  early  literature  upon  inflam- 
matory lesions  of  the  placenta  must  be  received  with  the  greatest  caution. 
At  the  same  time  acute  inflammation  of  the  placenta  is  occasionally  met 
with.  It  is  not  a.  primary  condition,  but  is  due  to  the  extension  of  a  similar 
process  from  the  dpr-idna.  the  latter  resulting  from  an  exacerbation  of  a  pre- 
existing chronic  gonorrhoea  or  from  an  acute  infection  due  to  the  gono- 
coccus  or  other  pyogenic  bacteria. 

In  several  instances,  upon  examining  sections  of  placental  tissue  under 
the  microscope,  I  found  the  decidua  serotina  infiltrated  with  leucocytes 
and  presenting  the  characteristic  picture  of  an  acute  inflammation,  while 
the  adjacent  intervillous  spaces  were  crowded  with  leucocytes.  Franque 
observed  similar  conditions,  but  is  inclined  to  believe  that  in  most  in- 
stances the  implication  of  the  placenta  is  secondary  to  the  death  of  the 
foetus. 

Tuberculosis  of  the  Placenta. — Tubercle  formation  i"  f1ip  fretal  portion 
of  the  placenta  is  extremely  vnfrpqnent.  For  particulars  concerning  the 
cases  which  have  thus  far  been  reported,  the  reader  is  referred  to  the  chap- 
ters upon  the  Physiology  of  the  Foetus  and  the  Infectious  Diseases  com- 
plicating Pregnancy. 

Calcification  of  the  Placenta. — Small  calcareous  nodules,  sometimes  oc- 
curring in  the  form  of  flat  plaques,  are  frequently  observed  upon  the  ma- 
ternal surface  of  the  placenta,  and  are  occasionally  so  abundant  as  to  cause 
it  to  resemble  a  piece  of  coarse  sand-paper.  Friinkel  showed  that  the  chalky 
material  was  usually  deposited  in  the  necrotic  tissue  surrounding  the  ends 
of  the  "  fastening  "  villi,  as  well  as  in  the  superficial  layers  of  the  decidua 
serotina. 

When  the  almost  universal  occurrence  of  degenerative  changes  in  the 
placenta  is  remembered,  it  should  be  a  matter  of  surprise,  not  that  calcifica- 
tion is  occasionally  met  with,  but  rather  that  it  is  not  noted  in  almost 
every  placenta,  inasmuch  as  apparently  ideal  conditions  for  its  formation 
are  constantly  present  in  the  later  months  of  pregnancy. 


■i 


508 


OBSTETRICS 


Abnormal  Adherence  of  the  Placenta. — In  the  vast  majority  of  cases  the 
term  adherent  placenta  is  a  misnomer,  since  the  interference  with  its 
expulsion  is  usually  clue  to  abnormalities  in  the  uterine  contractions  rather 
than  to  abnormal  adhesions  between  it  and  the  uterine  wall.  In  rare 
instances,  on  the  other  hand,  the  adhesions  may  be  so  firm  and  extensive 
that  spontaneous  separation  becomes  impossible,  and  occasionally  cannot 
be  effected  even  at  autopsy  except  by  tearing  either  the  placenta  or  the 
uterine  wall. 

Neumann  and  Hense  have  recently  examined  two  uteri  in  which  this 
condition  obtained.  Microscopic  examination  in  each  case  showed  that  the 
decidua  serotina  was  almost  entirely  absent,  and  that  the  chorionic  villi 
were  in  direct  contact  with  the  utpjinp  musr-le^nr!  the  connective  tissue 
separating'its  Hbres.  Under  such  circumstances  the  absence  of  the  spongy 
layer  of  the  decidua  readily  explains  the  clinical  phenomena. 

Abnormalities  of  the  Umbilical  Cord. — Variations  in  Insertion. — The 
umbilical  cord  is  usually  inserted  eccentrically  upon  the  foetal  surface  of 

the  placenta,  some- 
where between  its  cen- 
tre and  periphery.  A 
central  insertion  is 
less  common,  while  in 
a  still  smaller  number 
of  cases  the  junction 
has  taken  place  near 
the  margin,  giving 
rise  to  a  condition 
known  as  battledore . 
placenta. 

In  2,000  placentas 
examined  at  the  Johns 
Hopkins  Hospital  the 
insertion  was  eccentric 
in  73.25  per  cent,  cen- 
tral in  18.25  per  cent, 
and  marginal  in  7.25 
per  cent.     These  variations  possess  no  clinical  significance. 

On  the  other  hand  the  so-called  velamentous  insertion  of  the  cord — in- 


sertio  velamentosa — is  of  considerabTTpraHical  importance.  In  this  con- 
dition the  vessels  of  the  cord  separate  some  distance  from  the  placental 
margin  and  make  their  way  to  the  latter  in  a  fold  of  amnion  (Fig.  309). 
This  mode  of  insertion  was  noted  in  0.84  per  cent  of  15,894  placentae  ex- 
amined by  Lefevre,  and  in  1.25  per  cent  of  our  cases.  According  to  Miron- 
off  it  occurs  nine  times  more  frequently  in  twin  than  in  single  pregnancies, 
being  noted  in  5  and  0.57  per  cent  of  the  cases  respectively. 

Its  mode  of  production  has  given  rise  to  a  great  deal  of  speculation.  So 
long  as  the  old  views  were  in  vogue  concerning  the  part  played  by  the  allan- 
tois  and  the  amnion  in  the  formation-of  the  umbilical  cord,  Schultze's  ex- 
planation obtained  almost  universal  acceptance.     According  to  this,  the 


Fig.  457. — Marginal  Insertion  of  the  Cord.    Battledore 
Placenta. 


ABNORMALITIES  OF  THE    [JMBILICAL  CORD  509 

anomaly  was  the  resull  of  abnormal  adhesions  between  the  umbilical  vesicle 
and  the  chorionic  membrane,  whereby  the  amnion  was  prevented  from  ap- 
plying itself  in  the  usual  manner  to  the  cord.  At  present,  however,  the 
allantois  is  known  to  play  an  insignificant  part  in  the  formation  of  the  cord 
in  human  beings,  since  the  researches  of  His  have  clearly  shown  that  the 
abdominal  pedicle — the  forerunner  of  the  cord — is  present  from  the  earliesl 
periods,  and  represents  an  extension  of  the  caudal  end  of  the  embryo,  in 
which  the  allantois  is  represented  by  a  mere  epithelial  ductlet.  Moreover, 
the  cord  is  uol  provided  with  a  sheath  of  amnion,  and  therefore  abnormal 
adhesions  of  the  umbilical  vesicle  can  have  no  effect  upon  its  covering. 

Franque,  in  1900,  advanced  the  following  theory  as  to  the  mode  of  origin 
of  the  velamentous  insertion.    In  the  vast  majority  of  cases,  the  abdominal 
pedicle  extends  from  that  portion  of  the  chorion  which  is  in  contact  with  the 
most  richly  vascularized  portion  of  the  decidua — ordinarily  the  decidua  sero- 
tina — so  that  the  cord  becomes  inserted  upon  the  placenta.     Occasionally! 
however,  during  the  first  few  days  of  pregnancy,  the  area  of  greatest  vas-1 
cularization  may  be  in  the  decidua  reflexa,  and  the  abdominal  pedicle  then! 
takes  its  origin  from  the  portion  of  chorion  in  contact  with  it.     With  the  I 
advance  of  pregnancy,  however,  the  area  of  vascularization  shifts  to  the 
decidua  serotina — the  site  of  the  future  placenta — while  the  abdominal 
pedicle  retains  its  original  position,  and  from  its  maternal  end  the  vessels 
extend  to  the  placental  margin.      Peters,  while  recognising  the  fallacy 
of  Schultze's  explanation,  is  not  prepared  to  accept  that  proposed  by 
Franque. 

As  has  already  been  pointed  out,  the  velamentous  insertion  is  noted  com- 
paratively often  in  twin  pregnancy,  and  in  single-ovum  twins  is  supposed 
to  play  a  part  in  the  production  of  hydramnios.  According  to  Lefevre,  the 
condition  not  very  uncommonly  predisposes  to  premature  labour. 

When  the  placenta  is  inserted  low  down  in  the  uterus,  the  velamentous 
vessels  may  extend  partially  across  the  internal  os — vasaju^eyia — and  as 
dilatation  progresses  be  pressed  upon  the  presenting  part,  the  interference 
with  the  circulation  causing  asphyxia  of  the  foetus.  In  rare  cases  such 
vessels  are  torn  through  when  the  membranes  rupture,  and  the  f  cetUs  bleeds 
to  death.  The  full  literature  upon  this  subject  up  to  1898  has  been  col- 
lected by  Peiser,  while  Knapp  has  reported  a  case  in  which  the  accident  led 
to  the  death  of  both  twins  developed  from  a  single  ovum. 

Variations  in  Length  of  Cord. — Normally,  the  umbilical  cord  averages 
about  55  centimetres  in  length,  though  it  may  present  marked  variations — 
3.5  to  198  centimetres  (Dyhrenfurth  and  Hyrtl).  In  rare  instances  it  may 
be  so  short  that  the  abdomen  of  the  foetus  is  almost  in  contact  with  the  pla- 
centa, but  under  such  circumstances  a  congenital  umbilical  hernia  is  always 
present. 

According  to  Kaltenbach  the  cord  must  be  of  a  certain  length  in  order 
to  permit  of  delivery  of  the  child — that  is,  it  must  be  sufficiently  long  to 
reach  from  its  placental  insertion  to  the  vulva,  35  centimetres  when  the 
placenta  is  inserted  high  up,  and  20  centimetres  when  low  down.  As  a 
matter  of  fact  it  rarely  measures  lesTThan  25  centimetres. 

On  the  other  hand,  it  not  infrequently  happens  that  cords  which  actually 


510  OBSTETRICS 

exceed  the  normal  in  length  may  he  so  twisted  about  the  child  as  to  become 
practically  too  short.  Accordingly,  one  distinguishes  between  absolute  and 
accidental  or  relative  shortness  of  the  cord.  Either  of  these  conditions 
may  give  rise  to  serious  dystocia.  Brickner,  who  has  carefully  studied  the 
subject,  states  that  delivery  cannot  occur  under  such  circumstances  unless 
one  of  the  following  accidents  occur:  separation  of  the  placenta,  inversion 
of  the  uterus,  umbjljcal  hernia  of  thefcefus,  or  rupture  jjf.  the  cord,  the  last 
fwo^Demg  of  infrequent  occurrence. 

Rupture  of  the  cord  may  result  from  absolute  or  accidental  shortness, 
being  due  to  the  former  in  Dyhrenfurth's,  and  to  the  latter  in  Ahlfeld's 
case,  in  which  the  cord  measured  44  centimetres  in  length,  but  was  tightly 
twisted  about  the  foetus.  Ordinarily  an  excessively  long  cord  exerts  no  dele- 
terious influence,  although  it  predisposes  to  the  formation  of  loops  during 
pregnancy  and  to  prolapse  at  the  time  of  labour. 

Knots  of  the  Cord. — It  is  customary  to  distinguish  between  false  and 
true  knots,  the  former  being  due  to  developmental  abnormalities  in  the 
cord,  while  the  latter  result  from  the.  active  movements  of  the  child.  True 
knots  occur  very  frequently,  and  occasionally  are  of  the  most  complicated 
character.  Ordinarily  they  are  of  no  clinical  importance,  but  occasionally 
they  may  be  pulled  so  taut  as  to  compress  the  vessels  and  lead  to  asphyxia 
of  the  foetus. 

Loops  of  the  Cord. — The  cord  frequently  becomes  wrapped  around  por- 
tions of  the  foetus,  and  in  every  third  or  fourth  case  of  labour  the  child's 
neck  will  be  found  loosely  encircled  by  one  or  more  loops.  In  rare  instances 
these  may  produce  strangulation.  In  most  of  these  cases,  however,  the 
accident  is  not  due  to  any  drawing  taut  of  the  loop,  but  rather  to  the 
fact  that  it  does  not  become  looser  in  proportion  as  the  neck  of  the  child  in- 
creases in  size.  In  other  cases,  loops  of  the  cord  may  so  tightly  encircle 
the  body  or  one  of  the  extremities  of  the  child  as  to  give  rise  to  deep 
depressions,  which  in  extreme  cases  may  eventuate  in  the  strangulation  or 
gangrene  of  the  affected  part. 

In  single-ovum  twins  in  which  the  amniotic  partition  wall  has  been 
broken  through,  it  not  infrequently  happens  that  the  cord  of  one  foetus  may 
become  wrapped  around  some  portion  of  the  other  so  tightly  as  to  cause 
its  death.  A  number  of  cases  of  this  character  have  been  collected  by 
Hermann. 

Torsion  of  the  Cord. — As  the  result  of  movements  on  the  part  of  the 
foetus,  the  cord  may  become  more  or  less  twisted.  Occasionally  the  tor- 
sion is  so  marked  as  to  interfere  seriously  with  the  circulation.  The  most 
extreme  degrees  are  observed  only  after  the  death  of  the  foetus,  Schauta 
having  reported  a  case  in  which  380  twists  were  noted.  In  rare  instances 
separation  of  the  cord  is  produced,  though  this  is  possible  only  after  the 
death  of  the  foetus  in  the  early  months  of  pregnancy. 

Inflammation  of  the  Cord. — As  long  as  the  child  is  alive  inflammatory 
conditions  are  rarely  noted,  but  after  its  death  the  Whartonian  jelly  is 
found  to  be  infiltrated  with  leucocytes.  Not  uncommonly  obliterative 
changes  occur  in  the  vessels,  the  lumina  becoming  almost  completely  oc- 
cluded.   This  is  especially  liable  to  occur  in  syphilis,  although  it  is  observed 


FOETAL  SYPHILIS  51 1 

in  oilier  conditions,  and,  as  has  already  been  pointed  out,  is  believed  to  bo 
an  occasional  factor  in  the  production  of  tiydramnios. 

In  rare  instances  raritrs  of  I  lie  cord  may  be  subjected  to  undue  pressure 
as  the  result  of  sueh  changes"  !\Teier  has  reported  a  ease  in  which  the  death 
of  the  foetus  was  attributable  to  the  rupture  of  such  a  structure. 

Tumours  of  the  Conl. — Tumour  formations  implicating  the  cord  are 
rarely  seen.  I  heniatoniata  occasionally  result  from  the  rupture  of  a  varix 
with  subsequenl  ellusion  o*f  blood  into  the  cord.  In  one  instance  I  ob- 
served such  a  tumour,  5  centimetres  in  diameter,  at  the  foetal  end  of  the 
cord.  Alyxoniata  and  niyxosart'omata  have  also  been  described.  Winckel 
lias  reported  two  cases  of  sarcoma  of  the  cord,  while  Budin  has  described 
an  apparently  typical  dermoid. 

Cystic  structures  occasionally  occur  in  the  course  of  the  cord.  As  a 
rule  they  are  only  apparent,  and  result  from  the  liquefaction  of  the  myxom- 
atous tissue  of  the  cord.  In  other  cases,  as  reported  by  Kleinwachter,  they 
may  develop  from  the  duct  of  the  umbilical  vesicle,  which  is  included  in  the 
cord. 

(Edema  of  the  Cord. — This  condition  is  rarely  noted  by  itself,  but  not 
infrequently  complicates  ©edematous  conditions  of  the  foetus.  It  is  very 
common  in  dead  and  macerated  children.  In  one  of  my  cases,  in  which 
the  child  was  born  alive  at  full  term,  the  cord  was  3  centimetres  in  diameter 
and  resembled  an  eel  in  appearance.  Microscopic  examination  showed  that 
the  condition  was  simply  due  to  an  increase  in  the  amount  of  Whartonian 
jelly. 

Foetal  Syphilis. —  Syphilis  is  the  most  frequent  cause  of  foetal  death  in 
the  later jnontns" of  pregnancy,  and,  as  was  said  m  L'rTapter  XXA7,  may  be 
maternal  or  paternal  in  origin.  The  mother  may  be  suffering  from  the 
disease  at  the  time  of  conception,  or  ma}r  contract  it  during  the  course 
of  pregnancy.  In  the  one  case,  it  is  believed  that  transmission  to  the  foetus 
occurs  through  the  ovum,  Avhereas  in  the  other  it  takes  place  through  the 
placenta.  As  a  rule,  the  latter  mode  of  infection  is  possible  only  when 
the  mother  is  inoculated  during  the  early  months  of  pregnancy,  though 
exceptions  are  occasionally  noted.  So  far  as  my  oAvn  experience  goes, 
I  am  inclined  to  believe  that  in  most  instances  the  disease  is  paternal  in 
origin,  and  is  transmitted  by  the  spermatozoa.  In  such  cases  the  mother 
will  or  will  not  contract  the  disease,  according  as  the  father  does  or  does 
not  ^resent  infectious  lesions  at  the  time  of  coitus.  Since  these  are  usually 
absent,  the  foetus  ordinarily  becomes  inoculated,  while  the  mother  escapes 
— C  lips' 'S  law. 

Tt  has  long  been  known  that  a  syphilitic  infection  exerts  a  most  dele- 
terious influence  upon  the  product  of  conception.  It  frequently  is  respon- 
sible for  the  death  of  the  foetus  and  its  premature  expulsion  from  the 
uterus.  Less  commonly  the  child  is  born  alive  showing  distinct  manifesta- 
tions of  the  disease,  while  in  other  cases  they  do  not  appear  until  a  later 
period. 

It  is  of  the  greatest  importance  that  the  practitioner  should  become 
thoroughly  familiar  with  the  characteristic  lesions  of  foetal  and  placental 
syphilis,  as  upon  their  recognition  the  future  treatment  of  the  patient  often 


512 


OBSTETRICS 


depends.  This  is  a  point  especially  worthy  of  emphasis,  inasmuch  as,  in 
consequence  of  ignorance  or  design  on  the  part  of  one  or  both  parents,  the 
first  intimation  that  the  physician  has  of  the  existence  of  the  disease  is 
often  afforded  by  the  birth  of  a  dead  child  or  the  appearance  of  syphilitic 
stigmata  in  a  living  one. 

Syphilis  not  only  gives  rise  to.  characteristic  lesions  in  the  skin  and  in- 
ternal organs  of  the  foetus,  but  also  affects  the  placenta,  so  that  frequently 
a  diagnosis  can  be  made  from  an  examination  of  the  latter  organ.  This 
fact  is  of  special  importance  in  those  cases  in  which  the  foetus  is  born  alive, 
or  when  an  autopsy  is  not  permitted  upon  a  dead  child.  The  appearance  of 
the  syphilitic  foetus  varies  materially  according  as  it  is  born  alive  or  dead. 
In  either  instance  it  is  markedly  undersized,  and  the  subcutaneous  fat  is 
poorly  developed,  or  entirely  lacking.  In  the  living  child  the  skin  presents 
a  dry,  drawn  appearance,  and  has  a  peculiar  grayish  hue.    It  is  very  brittle, 


Fig.  458.  Fig.  459. 

Figs.  458,  459. — Normal  and  Syphilitic  Fcetal  Epiphysis.     X  2. 


especially  at  the  flexor  surfaces  of  the  joints,  where  abrasionsreadilv  occur 
and  expose  the  underlying  corium.  The  skin  covering  the  soles  of  the  feet 
and  palms  of  the  hands  is  often  thickened  and  glistening,  and  suggests  the 
condition  observed  in  the  hands  of  washerwomen.  In  other  cases,  charac- 
teristic cutaneous  lesions  are  noted,  particularly  the  appearance  of  pem- 
phigoid vesicles  upon  the  palms  of  the  hands  and  soles  of  the  feet. 

If  intra-uterine  death  has  occurred,  the  foetus  rapidly  undergoes  macera- 
tion, the  skio,  peeling  off  upon  the  slightest  touch  and  exposing  the  under- 
lying discoloured  corium.  Inexperienced  persons  have  regarded  this  con- 
dition in  itself  as  due  to  syphilis,  but  it  is  by  no  means  pathognomonic,  since 
it  occurs  in  all  macerated  children,  no  matter  what  the  cause  of  death. 
At  the  same  time  it  must  be  remembered  that  this  defect  may  entirely  oblit- 
erate or  at  least  obscure  the  specific  skin  lesions. 

The  lesions  in  the  internal  organs  consist   essentially  in  interstitial 


FCETAL  SYPHILIS 


513 


Fig.  460. — Normal  Fcetal  Ei 
physis.     X  60. 


changes  in  the  lungs,  liver,  spleen,  and  pan- 
creas, and  osteochondritis  m  the  longlmncs. 
IT  is  generally  stated  thai  the  Lungs  fre- 
quently contain  gummatous  nodules.  'These. 
however,  were  Lacking  in  the  specimens  which 
I  have  examined.  In  many  eases  the  lungs 
arc  enlarged,  pale,  and  scarcely  float  when 
thrown  into  water.  On  microscopic  examina- 
tion the  alveoli  are  found  filled  with  cast-off 
epithclh 


catarrhal  pneumonia,  the 
pneumonia  alba  of  Virchow.  In  other  eases 
the  lesion  consists  in  an  increase  in  the  inter- 
stitial tissue  between  the  alveoli,  by  which  the 
latter  are  compressed,  but  do  not  become  quite 
impervious  to  air.  These  changes  have  been 
exhaustively  studied  by  Heller. 

As  the  result  of  hypertrophic  cirrhosis,  the 
liver  undergoes  a  marked  increase  in  size,  and 
according  to  Huge  its  weight  may  equal  one 
tenth  or  even  one  eighth  of  that  of  the  whole 
body,  instead  of  one  thirtieth  as  usual.    Under 

the  microscope  there  is  a  marked  increase  in  the  connective  tissue  sur- 
rounding the  individual  lobules  and  acini,   with   here  and  there"  small 

__^      areas  of  round-cell  in- 

filtration. 

The  spleen  likewise 
undergoes  interstitial 
changes  and  increases 
markedly  in  size,  so 
that  it  frequently 
weighs  two  or  three 
times  as  much  as  usual, 
which,  roughly  speak- 
ing,  is  one  three-hun- 
dredth s  of  the  bo  dy 
weight.  The  pancreas 
also  presents  intersti- 
tial changes,  and  is 
slightly  larger  than 
normal. 

The  recognition  of 
these  lesions  requires 
some  little  pathological 
experience,  though  if 
the  liver  and  spleen  are 
found  markedly  increased  in  size  and  weight  the  diagnosis  of  syphilis  is 
permissible. 

A  much  more  characteristic  sign,  and  one  which  is  readily  detected,  is 


Fig.  461. — Syphilitic  Fcstal  Epiphysis.     X  60. 


514 


OBSTETRICS 


\M 


afforded  by  changes  occurring  at  the  junction  of  the  epiphysis  with  the 
diaphvsis  in  the  long  bones — Werner's  bone  disease.  Xormally  the  two 
are  separated  by  a  narrow,  -whitish,  slightly  curved  line,  0.5  to  1  milli- 
metre in_  diameter — Guerin's  line — representing  the  area  of  preliminary 
calcification,  which  constitutes  the  scaffolding  upon  which  the  new  bone 
is  developed.  In  syphilis,  on  the  other  hand,  this  undergoes  characteristic 
changes,  becoming  converted  into  an  irregular,  jagged,  yellowish  line  2, 
or  more  millimetres  in  thickness.     In  advanced  cases  this  alteration 


is  associated  with  considerable  softening  and  the  formation  of  a  soft  pul- 
taceous  material,  which  occasionally  leads  to  complete  separation  of  the 
epiphysis  (Tigs?458  and  459). 

Upon  microscopical  examination  of  the  normal  epiphysis,  as  shown  in 
Fig.  460,  the  cartilage  cells  are  found  to  be  arranged  in  parallel  rows  a 


v.  Q  ' 


v 


Fig.  462.  Fig.  463. 

Figs.  462,  46-3. — Xormal  and  Syphilitic  Chorionic  Villi  teased  out  in  Salt  Solution. 

Slightly  Magnified. 


right  angles  to  Guerin's  line,  while  below  it  is  the  typical  bony  structure  of 
the  diaphysis  with  its  marrow  cavities.  The  line  itself  is  formed  by  a  depo.;l . 
of  lime  salts  between  the  median  ends  of  the  rows  of  cartilage  cells,  and  is 
gradually  invaded  by  the  newty  formed  bone. 

In  syphilis,  as  is  illustrated  in  Fig.  461,  the  changes  are  due  to  osteo- 
chondritis, as  the  result  of  which  there  is  no  longer  a  gh_arplv_mai'kecL  zone 
of  preliminary  calcification  between  the  cartilage^  and  the  growing  bone; 
but  areas  of  bone  formation  and  calcification  are  found"  scattered  irregu- 
larly through  the  lower  portions  of  the  epiphysis,  giving  an  irregular  ap- 
pearance to  this  region. 

These  changes  have  been  carefully  studied  by  Wegner  and  E.  Miiller. 


PLACENTAL   SYPHILIS 


515 


ami  are  most  readily  recognisable  at  the  lower  end  of  the  femur,  and  fairly 
well  .11  the  lower  ends  of  the  tibia  and  radius.  They  are  less  clearly 
denned  at  the  upper 
ends  of  the  tibia,  fibu- 
la, and  femur,  and 
only  in  rare  instances 
ran  they  be  made  ou1 
at  the  ends  of  the  ribs. 
They  are  extremely 
characteristic,  and 
their  detection  iustt- 
fies  one  in  making  a 


Fig.  464. — Normal  Full-Term  Placenta.     X  50. 


positive  diagnosis  and 
placing  the  patient 
under  specific  treat- 
ment. 

Placental  Syphilis. 
— Under  the  influence 
of  syphilitic  infection 
the    placenta    under- 
goes very  characteris- 
tic   changes.      It    be- 
comes  larger  and  paler 
in  colour,  and  if  the 
foetus    is   dead    often 
presents  a  dull,  greasy 
appearance.      Its    in- 
crease  m  "size  is  very 
marked,    and    accord- 
ing to  the  re 
of     Correa-Dias 
Schwab,  which 
been  able  to 
instead   of   one 
it    may    represent 
much  as  one  fo_ 
even  a  larger  frac 
of    the    entire 
weight  of  the  ttetuljZ 

cJxill  more  charac- 
teristic,  however,  are 
the  changes  in  the 
chorionic  villi,  to 
which  Frank  el  called 
attention  in  1873.  In 
syphilis  the  villi,  when 

teased  out  m  salt  solution,  are  seen  to  have  lost  their  characteristic  arbor- 
escent  appearance  and  to  have  become  thicker  and  more  club-shapedTFigs. 
34  ' 


Fig.  465. — Syphilitic  Full-Term  Placenta.     X  50. 


516  OBSTETRICS 

462  and  463).  At  the  same  time  there  is  a  marked  decrease  in  the  number 
of  blood-vessels,  which  disappear  almost  entirely  in  advanced  cases.  This 
results  partly  from  endarteritic  changes,  but  principally  from  a  prolifera- 
tion  of  the  stroma  cells,  wlncli  lose  their  normal  stellate  appearance,  be- 
coming round  or  oval  in  shape,  and  closely  packed  together. 

Similar  changes  are  observed  in  sections  made  from  hardened  speci- 
mens. As  will  be  seen  on  comparing  Figs.  464  and  465,  the  individual  villi 
are  markedly  increased  in  size  and  almost  devoid  of  blood-vessels,  while 
their  stroma  is  made  up  of  closely  packed,  round,  or  oval  cells.  This  appear- 
ance is  so  characteristic  as  to  enable  one  with  a  little  practice  to  make  a 
probable,  if  not  a  positive  diagnosis,  and  at  the  same  time  affords  a  satis- 
factory explanation  for  the  poor  development  of  the  foetus. 

It  is  generally  stated  that  distinct  syphilitic  lesions,  varying  from  a 
marked  thickening  of  the  membrane  to  distinct  gumma  formation,  are  fre- 
quently noted  in  the  decidua.  I  am  inclined  to  believe,  however,  that 
many  of  the  conditions  which  have  been  described  as  such  have  no  connec- 
tion with  lues,  but  are  analogous  to  the  various  hyperplastic  conditions  of 
the  decidua,  which  were  formerly  attributed  to  the  same  cause. 

Zilles,  and  many  of  the  earlier  writers,  described  gummata  occurring 
in  the  foetal  portion  of  the  placenta.  I  have  never  met  with  such  lesions, 
and  am  of  the  opinion  that  careful  histological  study  will  show  that  the 
majority  of  the  so-called  placental  gummata  are  merely  infarcts  in  various 
stages  of  development  or  degeneration. 

General  Dropsy  of  the  Foetus. — In  this  rare  condition,  65  instances  of 
which  have  been  collected  by  Ballantyne,  the  foetus  and  placenta  are  mark- 
edly ©edematous.  As  the  result  of  infiltration  with  serum  the  former  may 
attain  immense  proportions  and  the  latter  be  increased  to  three  or  four 
times  its  normal  size.  In  a  case  recently  under  my  observation  the 
foetus,  at  the  seventh  month  of  pregnancy,  weighed  1,140  and  the  pla- 
centa 1,200  grammes.  Cohn  has  described  a  placenta  weighing  2,900 
grammes. 

Although  a  good  deal  has  been  written  upon  the  subject,  no  satisfactory 
explanation  of  the  anomaly  has  as  yet  been  arrived  at.  Formerly  it  was 
supposed  to  result  from  oedematous  conditions  of  the  mother,  but  the 
researches  of  Ballantyne  have  shown  that  this  view  does  not  always  hold 
good,  and  that  in  the  majority  of  the  cases  submitted  to  a  thorough  study 
lesions  were  noted  in  the  organs  of  the  foetus  sufficient  to  explain  the  pro- 
duction of  the  condition.  It  is  interesting  to  note  that  in  several  cases 
collected  by  Seifert  it  was  attributed  to  foetal  leukaemia. 

The  disease  always  1  earls  to  the  death  of  the  foetus,  which  in  no  in- 
stance survived  its  birth  for  more  than  a  lew  Uours.  In  the  majority  of 
cases  on  record  labour  was  spontaneous,  though  occasionally  the  increased 
size  of  the  foetus  and  the  placenta  may  give  rise  to  dystocia. 

Diseases  of  the  Foetus. — In  most  text-books  upon  obstetrics,  numerous 
morbid  conditions  of  the  foetus  are  described  under  this  heading.  The  ma- 
jority of  them,  however,  are  of  interest  mainly  from  a  pathological  point 
of  view,  and  have  no  obstetrical  significance,  except  in  those  cases  in  which 
they  lead  to  an  increase  in  the  bulk  of  the  foetus,  which  in  turn  may  give 


DISHASKS    AND   ABNORMALITIES   OE.   THE   OVUM  517 

rise  io  dillicull  labour.  Accordingly,  they  will  not  be  considered  in  this 
place,  though  certain  of  them  will  be  referred  to  in  the  chapter  upon  Foetal 
Dystocia. 

LITERATURE 

Ackermann.     Der  weisse  Infarct  der  Placenta.     Archiv  f.  path.  Anat.,  1884,  xevi,  439-452. 
Zur  normalen  u.  path.  Anat.  der  nienschlichen  Placenta.    Virchow's  Festschrift,  Berlin, 

1891,  585-616. 

Ahlfeld.    Multiple  Dermoidcysten  des  Amnion.     Berichte  u.  Arbeiten,  1885,  ii,  200-202. 
Die  Yerwachsungen  des  Amnion  mit  der  Oberiiache  der  Frucht.     Berichte  u.  Arbeiten, 

1887,  iii,  158-165. 
Zerreissung  der  Nabelschnur  eines  reifen  Kindes  wahrend  der  Gcburt.     Zeitschr.  f. 

Geb.  u.  Gyn.,  1897,  xxxvi,  467-472. 
Mangel  des  Fruchtwassers.     Lehrbuch  der  Geb.,  1898,  II.  Aufl.,  271. 
Aichel.     Ueber  die  Blasenmole  eine  experimentelle  Studie.     Habilitationsschrift,  Er- 

langen,  1901. 
Albert.     Ueber  Angiome  der  Placenta.     Archiv  f.  Gyn.,  1898,  lvi,  144-159. 
Ballaxtyxe.     General  Dropsy  of  the  Foetus.     The  Diseases  of  the  Foetus,  Edinburgh, 

1892,  i,  102-164. 

Bar.     Recherches  pour  servir  a  Phistoire  de  l'hydramnios.     These  de  Paris,  1881, 
Bode  und  Schmorl.     Ueber  Tumoren  der  Placenta.     Archiv  f.  Gyn.,  1898,  lvi,  73-83. 
Boivin,  Madame.     Nouvelles  recherches  sur  la  nature,  l'origine  et  le  traitement  de  la 

mole  vesiculaire.     Paris,  1827. 
Braun,  G.     Ligatur  der  Nabelschnur  durch  Amnionstrange.     Zeitschr.  f.  Ges.  d.  Aerzte 

zu  Wien,  1854,  ii,  192. 
Breslau  und  Eberth.     Diffuses  Myxom  der  Eihaute.    Virchow's  Archiv,  1867,  xxxix, 

191-192. 
Brickxer.     A  New  Symptom  in  the  Diagnosis  of  Dystocia  due  to  a  Short  Umbilical 

Cord.     Amer.  Jour.  Obst.,  1902,  xlv,  512-521. 
Budix.     Note  sur  une  tumeur  du  cordon  ombilical.     Femmes  en  couches  et  nouveau-nes, 

1897,  179-184. 
Tarnier  et  Budin,  Traite  des  l'art  des  accouchements,  1886,  ii,  276. 
Cagxy.     Heraorrhagies  placentaires  de  l'albuminurie.     These  de  Paris,  1891. 
Clarke.    Account  of  a  Tumour  found  in  the  Substance  of  the  Human  Placenta.     Phil- 
osophical Transactions,  London,  1798. 
Cohn.    Ueber  das  Absterben  des  Foetus  bei  Nephritis  der  Mutter.    Zeitschr.  f.  Geb.  u. 

Gyn.,  1888,  xiv,  596. 
Correa-Dias.     De  l'hypertrophie  placentaire  dans  les  cas  de  syphilis.     These  de  Paris, 

1891. 
Dorlaxd  and  Gerson.     Cystic  Disease  of  the  Chorion.     University  Medical  Magazine, 

May,  1896,  565-590. 
Dyhrenfurth.     Inversio  uteri  bedingt  durch  zu  kurzen  Nabelstrang.     Centralbl.  f.  Gyn., 

1885,  801-804. 
Edex.     Deciduoma  Malignum :  A  Criticism.     Trans.  Lond.  Obstet.  Soc,  1896,  xxxviii, 

149-162. 
A  Study  of  the  Human  Placenta.     Jour.  Path,  and  Bacteriology,  1897,  v,  265-282. 
Ehrexdorfer.     Cysten  und  cystoide  Bildungen  der  nienschlichen  Placenta.     Wien,  1893. 
Fehling.     Ueber  die  physiologische  Bedeutung  des  Fruchtwassers.    Archiv  f.  Gyn.,  1879, 

xiv,  221-244. 
Fraxkel.     Ueber  Verkalkungen  der  Placenta.     Archiv  f.  Gyn.,  1871,  ii,  373-382. 

Ueber  Placentarsyphilis.     Archiv  f.  Gyn.,  1873,  v,  1-54. 
Fraexkel.     Die  Histologic  der  Blasenmole,  etc.     Archiv  f.  Gyn.,  1895,  xlix,  481-507. 


518  OBSTETRICS 

Franque.     Anat.  unci  klin.  Beobachtungen  iiber  Plaeentarerkrankungen.     Zeitschr.  f. 

Geb.  u.  Gyn..  1894,  xxviii,  293-348. 
Ueber  histologisehe  Veranderungen  in  der  Placenta  und  ihre  Beziehungen  zum  Tode 

der  Frucht.     Zeitschr.  f.  Geb.  u.  Gyn.,  1897,  xxxvii,  277-298. 
Die  Entstehung  der  velamentosen  Insertion  der  Nabelschnur.     Zeitschr.  f.  Geb.  u.  Gyn., 

1900,  xliii,  463-488. 
Gassner.     Menge  des  Fruchtwassers.     Monatsschr.  f.  Geburtsk.,  1862,  xix,  30-33. 
Goeze.     Quoted  by  Kossmann. 

von  Grafenberg.     Observationes  medicae  rariores.     Frankfurt,  1565. 
Gueniot.     Tumeur  du  placenta  observee  chez  une  prirnipara.     L'Obstetrique,  1897,  ii, 

275-276. 
Heller.     Die  Lungenerkrankungen  bei  angeborener  Syphilis.     Deutsehes  Archiv  f.  klin. 

Med.,  xliii,  159. 
Hense.     Adharenz  der  Placenta.     Zeitschr.  f.  Geb.  u.  Gyn.,  1901,  xlv,  272-279. 
Hermann.     Ueber  Verschlingungen  der  Nabelschniire  bei  Zwillingen.     Archiv  f.  Gyn., 

1891,  xl,  253-260. 
Hyrtl.     Die  Blutgefasse  der  menschlichen  Nachgeburt.     Wien,  1870. 
Jaggard.     Note  on  Oligohydramnion.     Amer.  Jour.  Obst.,  1894,  xxix,  432-446. 
Jarotsky  und  Waldeyer.     Traubenmole  in  Verbindung  mit  dem  Uterus,  etc.     Virchow's 

Archiv,  1867,  xli,  528-534. 
De  Jong.     Ueber  das  Entstehung  von  Cysten  in  der  Placenta.     Monatsschr.  f.  Geb.  u. 

Gyn.,  1900,  xi,  1072-1092. 
Jungbluth.     Zur  Lehre  vom  Fruehtwasser,  etc.     Archiv  f.  Gyn.,  1872,  iv,  554-557. 
Kahn-Bensinger.     Myxoma  chorii  bei  einem  Zwillingsei.     D.  I.,  Giessen,  1887. 
Kaltenbach.     Zu  kurze  Nabelschnur.     Lehrbuch  der  Geb.,  1893,  316. 
Kanthack.    Discussion  on  Deciduoma  Malignum.     Trans.  Lond.  Obst.  Soc,  1896,  xxxviii, 

171-184. 
Kehrer.     Ueber  Traubenmolen.     Archiv  f.  Gyn.,  1894,  xlv,  478-505. 
Kermauner.     Zur  Lehre  von  der  Entwickelung  der  Cysten  u.  des  Infarctes  in  der  mensch- 
lichen Placenta.     Zeitschr.  f.  Heilkunde,  1900,  xxi,  1-36. 
Kleinwachter.    Ein  Beitrag  zur  Anatomie  des  Ductus  omphalo-mesentericus.     Archiv 

f.  Gyn.,  1876,  x,  238-247. 
Knapp.     Eineiige  Zwillingsplacenta :  velamentose  Insertion  ;  Verblutung  beider  Fruchte 

unter  der  Geburt.     Archiv  f.  Gyn.,  1896,  li,  586-594. 
Kossmann.     Zur  Geschichte  der  Traubenmole.    Archiv  f.  Gyn.,  1900,  lxii,  153-169. 
Krieger.     Fall  von  interstitiellen  Molenbildung.     Berliner  Beitrage  zur  Geb.  u.  Gyn., 

1872,  i,  10-15. 
Kustner.     Hydramnios.     Muller's  Handbuch  der  Geburtsh.,  1889,  ii,  557-579. 
Mehrfache  Placenta,  etc.     Muller's  Handbuch  der  Geburtsh.,  1889,  ii,  624-625. 
Ueber  eine  noch  nicht  bekannte  Entstehungsursache  amputirender  amniotischer  Faden 

u.  Strange.     Zeitschr.  f.  Geb.  u.  Gyn.,  xx,  445-458. 
Ladinski.     Deciduoma  Malignum.     Amer.  Jour.  Obst.,  1902,  xlv,  465-509. 
Lebedeff.     Quelques  donnees  sur  la  fonction  physiologique  de  l'amnios.     Annales  de 

gyn.  et  d'obst.,  1878,  ix,  241-251. 
Lefevre.     De  l'insertion  velamenteuse  du  cordon.     These  de  Paris,  1896. 
Levison.     Fruehtwasser  und  Hydramnios.     Archiv  f.  Gyn.,  1876,  ix,  517-519. 
Levy.     Rapports  existant  entre  le  poids  du  foetus  et  celui  du  placenta.     These  de  Paris, 

1900. 
Marchand.     Ueber  die  sogenannten  "  decidualen  "  Geschwiilste,  etc.     Monatsschr.  f.  Geb. 

u.  Gyn.,  1895,  i,  419-438;  513-560. 
Ueber  den  Bau  der  Blasenmole.     Zeitschr.  f,  Geb.  u.  Gyn.,  1895,  xxxii,  405-472. 
Die  Blasenmole.     Zeitschr.  f.  Geb.  u.  Gyn.,  1898,  xxxix,  206-216. 
Ueber  das  maligne  Chorionepitheliom,  nebst  Mittheilung  2  neuen  Falle.     Zeitschr.  f. 

Geb.  u.  Gyn.,  1898,  xxxix,  173-258. 


DISEASES   AND   ABNORMALITIES  OF  THE   OYLM  519 

Martin.     De  I'influence  des  alterations  du  placenta  sur  la  developmenl  du  foetus.    These 
de  Paris,  1896. 

Montgomery.      On   tlic  Spontaneous  Amputation  of  the  Foetal  Limbs  in  Utero.      An 

Exposition  of  the  Signs  and  Symptoms  of  Pregnancy.     1863,  2d   <<1.  ( reprint. -d), 

625-695. 
MOller,  K.     Beitrag  zur  path.  Anatomie  der  Syphilis  hereditaria.     Virchow's  Archiv, 

1883,  x.ii.  523-556. 
MCxzek.     Chorioepithelioma  malignum.     Centralbl.  f.   allg.   Path.  u.  path.  Anatomie, 

1902,  xiii.  L97-265. 
Neumann.     Beit  rag  zur  Lehre  von  der  Anwachsung  der  Placenta.     Monatsschr.  f.  Geb. 

u.  Gyn.,  1896,  iv,  307-318. 
Beitrag  zur  Kenntniss  der  Blasenrnole,  etc.     Monatsschr.  f.  Geb.  u.  Gyn.,    1807.  vi, 

17-36;  157-177. 
Niebebding.     Zur  Genese  des  Hydramnios.     Archiv  f.  Gyn.,  1882,  xx,  310-316. 
Niebergall      Leber  Placentargeschwiilste.     Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  vi,  H.  5. 
Opitz.     Beitrage  zur  Aetiologie  des  Hydramnios.     Centralbl.  f.  Gyn.,  1898,  553-560. 
Orth.     Infarct  der  Placenta.     Lehrbuch  der  spec.  path.  Anat.,  1893.  ii.  603-607. 
Osterloh.     Kapillarangiom  der  Placenta.     Centralbl.  f.  Gyn.,  1899,  1232. 
Ouvby.     Etude  de  la  mole  hydatidiforme.     These  de  Paris,  1897. 
Peiser.     Verblutungstod  der  Frucht  in  folge  Ruptur  einer  Umbilicalarterie  bei  Insertio 

velamentosa.     Monatsschr.  f.  Geb.  u.  Gyn.,  1898.  viii,  619-624. 
Beitrag  zur  Pathologie  der  Placenta.     Monatsschr.  f.  Geb.  u.  Gyn.,  1899,  x,  613-626. 
Percy.     Memoire  sur  les  hydatides  uterines,  etc.     Jour,  de  med.  chir.  et  pharm.,  Paris, 

1811,  p.  171. 
Peters.     Beitrag  zur  Casuistik  der  Vasa  praevia,  etc.     Monatsschr.  f.  Geb.  u.  Gyn..  1901, 

xiii.  1-21. 
Pick.     Von  der  gut-  und  bos-artig  metastasirenden  Blasenmole.     Berliner  klin.  "Wochen- 

schr..  1897,  1069-1073  ;  1007-1102. 
Pierce.     Chorio-epithelioma  malignum.     Amer.  Jour.  Obst.,  1902,  xlv,  321-351. 
Potex.     Die  Verschleppung  der  Chorionzotten.     Archiv  f.  Gyn.,  1902,  lxvi,  590-617. 
Potex  und  Vassmer.     Beginnendes  Syncytiom  mit  Metastasen,  beobachtet  bei  Blasen- 

molenschwangersehaft.     Archiv  f.  Gyn..  1900,  lxi,  205-276. 
Ribemoxt-Dessaigxes.     Des  placentas  multiples  dans  les  grossesses  simples.     Annales  de 

Gyn.  et  d'Obst.,  1887,  xxvii.  12-52. 
Rossier.     Klin,  und  histolog.  Untersuchungen  fiber  die  Infarcte  der  Placenta.     Archiv 

f.  Gyn.,  1888,  xxxiii,  400-412. 
Ruge.     Leber  den  Foetus  sanguinolentus.     Zeitschr.  f.  Geb.  u.  Gyn.,  1877,  i,  57-119. 
Sallixger.     Leber  Hydramnios,  etc.     D.  L,  Zurich.  1875. 
SInger.     Deciduoma  malignum.     Verh.  d.  deutschen  Gesellsch.  f.  Gyn..  1892,  iv,  333. 

Sarcoma  uteri  deciduo-cellulare.  etc.     Archiv  f.  Gyn.,  1893,  xlix,  89-149. 
Schaller.     Leber   Phloridzin-diabetes  Sehwangerer,   etc.     Archiv  f.  Gyn.,  1899,  lvii, 

566-596. 
Schatz.     Eine  besondere  Art  von  einseitiger  Polyhydramnie,  etc.     Archiv  f.  Gyn.,  1882, 

xix,  329-369. 
Schauta.    Zur  Lehre  von  der  Torsion  der  Xabelschnur.     Archiv  f.  Gyn.,  1881,  xvii.  19-23. 
Schlagexhaufer.     Zwei  Falle  von  Tumoren  des  Chorionepithels.     Wiener  klin.  TVochen- 

schr..  1899.  Nr.  18. 
Schmidt.     Zur  Kasuistik  der  chorio-epithelialen  Scheidentumoren.     Centralbl.  f.  Gyn., 

1900,  1257-1265. 
Ein  neuer  Fall  von  primaren  Chorio-epitheliom  der  Scheide.     Centralbl.  f.  Gyn.,  1901, 

1350. 
Schmorl.     Demonstration  eines  syncytialen  Scheidentumors.     Centralbl.  f.  Gyn..  1897, 

1217. 
Schxeider.     Quoted  by  Kiistner. 


520  OBSTETRICS 

Schultze.     Die  genetische  Bedeutung  der  velamentalen  Insertion  des  Nabelstranges. 

Jenaisehe  Zeitsehr.  f.  Med.  u.  Naturwiss.,  1867,  iii,  198. 
Ueber  velementale  u.  plaeentale  Insertion  der  Nabelschnur.     Arcbiv  f.  Gyn.,  1887,  xxx, 

47-56. 
Schwab.     De  la  syphilis  du  placenta.     These  de  Paris,  1896. 

De  la  mole  hydatidiforme.     L'Obstetrique,  1898,  iii,  405-427. 
Simonart.     Note  sur  les  amputations  spontanees.    Archiv  de  medecine  Beige,  1845,  T.  18, 

112-119. 
Steffeck.    Der  weisse  Infarct  der  Placenta.     Hofmeier,  "  Die  Placenta,"  Wiesbaden, 

1890,  91-116. 
Van  dee  Hoeven.     Ueber  die  Aetiologie  der  Mola  hydatidosa,  etc.     Archiv  f.  Gyn.,  1901, 

lxii,  316-347. 
Vassmer.    Zur  Aetiologie  der  Placentarcysten.     Archiv  f.  Gyn.,  1902,  lxvi,  49-69. 
Veit.     Das  Deciduome  malignum.    Yeit's  Handbuch  der  Gyn.,  1899,  iii,  2te  Halfte,  erste 

Abth.,  535-596. 
Ueber  Deportation  vom  Chorionzotten.     Zeitsehr.  f.  Geb.  u.  Gyn.,  1901,  xliv,  466-504. 
Velpeau.     Quoted  by  Virchow. 
Virchow.     Myxom  der  Placenta.     Die  krankhaften  Geschwiilste,  1863,  i,  405-414. 

Myxom  fibrosum  placenta?.     Die  krankhaften  Geschwiilste,  1863,  i,  415. 
Volkmann.     Ein  Fall  von  interstitieller  Molenbildung.     Virchow's  Archiv,   1867,  xli, 

528-534. 
Wegner.     Ueber  hereditare  Knochensyphilis  bei  jungen  Ivindern.     Virchow's  Archiv, 

1870,  1,  305-323. 
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Williamson.    The  Pathology  and  Symptoms  of  Hydatidiform  Degeneration  of  the  Chorion. 

Trans.  London  Obst.  Soc,  1900,  xli,  303-338. 
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397. 
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1885. 


CHAPTEE  XXIX 
ABORTION,   MISCARRIAGE,   AND  PREMATURE  LABOUR 

Spontaneous  expulsion  of  the  ovum  may  occur  at  any  period  of  preg- 
nancy, and  is  variously  designated  according  to  the  degree  of  development 
which  the  product  of  conception  has  attained.  Thus,  it  is  customary  to 
speak  of  abortion,  of  miscarriage,  or  of  prpmatm-p  fiihrmr  respectively, 
according  as  pregnancy  has  terminated  before  the  sixteenth  week,  between 
the  sixteenth  and  twenty-eighth  week,  or  at  a  later  period. 

Prior  to  the  sixteenth  week,  owing  to  the  imperfect  development  of 
the  placenta,  the  entire  ovum  often  comes  away  intact.  From  that  time 
on,  however,  the  placenta  forms  a  definite  organ  and  the  expulsion  of  an 
intact  ovum  is  exceptional,  the  foetus,  as  a  rule,  being  extruded  first,  and 
followed  after  a  longer  or  shorter  period  by  the  placenta  and  membranes. 
After  the  twenty-eighth  week  the  course  of  labour  differs  but  little  from 
that  observed  at  full  term,  and  the  child,  if  properly  cared  for,  may  survive, 
its  chances  of  so  doing  increasing  in  almost  geometrical  proportion  with 
every  additional  week. 

As  the  term  abortion  is  somewhat  suggestive  of  a  criminal  procedure,  it 
is  rarely  employed  in  popular  parlance,  all  cases  terminating  prior  to  the 
period  of  viability  being  designated  as  miscarriages.  Among  medical  men, 
on  the  other  hand,  the  latter  term  is  but  little  used,  and  it  is  customary 
to  speak  of  all  cases  ending  before  tlm  ttrp-ntv-pi'o-hth  wppk  as  abortions^. 

Frequency. — It  is  difficult  to  arrive  at  accurate  conclusions  concerning 
the  frequency  with  which  abortion  occurs.  Inasmuch  as  a  comparatively 
small  proportion  of  such  cases  are  treated  in  the  lying-in  hospitals,  the 
statistics  based  upon  their  records  would  give  too  low  an  estimate.  On  the 
other  hand,  sufficiently  large  series  from  private  practice  are  not  available. 
Franz  states  that  abortion  occurred  in  15.4  per  cent  of  the  cases  ad- 
mitted to  the  lying-in  hospital  at  Halle,  the  accident  being  more  than  twice 
as  frequent  in  multipara?  as  in  primiparae.  A  conservative  estimate  would 
indicate  that  about  every  fifth  or  sixth  pregnancy  in  private  practice  ends 
in  abortion,  and  the  percentage  would  be  increased  considerably  were  the 
very  early  cases  taken  into  account,  in  which  there  is  profuse  loss  of  blood 
following  the  retardation  of  the  menstrual  period  for  a  few  weeks. 

2Etiology. — In  the  early  months  of  pregnancy  spontaneous  expulsion  of 
the  ovum  is  nearly  always  preceded  by  the  death  of  the  foetus.  For  this 
reason  the  consideration  of  the  aetiology  of  abortion  practically  resolves 

521 


522  OBSTETRICS 

itself  into  determining  the  cause  of  foetal  death.  In  the  later  months,  on 
the  other  hand,  the  foetus  is  frequently  born  alive,  and  other  factors  must  be 
looked  for  to  explain  its  expulsion.  Foetal  death  may  be  due  to  abnormali- 
ties occurring  in  the  ovum  itself  or  due  to  some  disease  on  the  part  of  the 
mother,  and  now  and  again  of  the  father. 

(a)  The  death  of  the  foetus  is  frequently  due  to  abnormalities  in  the 
development  of  the  embryo  which  are  inconsistent  with  foetal  life.  More 
often,  however,  it  results  from  changes  m  the  foetal  appenclag_es7"which 
interfere  with  its  nutrition,  such  as  excessive  torsion  ot  tlie  aH^dThydram- 
nios,  hvdaticliform  mole,  or  syphilis.  In  the  last  two  affections  the  nutri- 
tive^ material  conveyed  by  the  maternal  vessels  to  the  intervillous  spaces 

merely  suffices  to  nourish  the  hypertrophic  chorionic  villi,  little  or  none 
remaining  to  be  transmitted  to  the  child. 

Again,  other  diseases  and  abnormalities  of  the  placenta  may  lead  to  the 
same  result.  Thus  Merttens  and  Franque  have  described  an  obliterating 
endarteritis  in  the  vessels  of  the  chorionic  villi,  independent  of  syphilis, 
which  interferes  with  the"  foetal  circulation  to  such  an  extent  as  to  be  in- 
compatible with  life.  In  other  cases,  the  abundant  formation  of  red  and 
white  infarcts  may  throw  so  large  a  portion  of  the  placenta  out  of  func- 
tion that  the  remainder  is  not  sufficient  to  supply  the  needs  of  the  foetus. 
Abnormalities  in  development,  such  as  placenta  prgevia  or  velamentous  in- 
sertion of  the  cord,  as  well  as  premature  separation  of  the  placenta,  may 
likewise  bring  about  circulatory  conditions  inconsistent  with  foetal  life. 

(b)  As  was  pointed  out  in  the  chapter  upon  the  Accidental  Complications 
of  Pregnancy,  all  acute  infectious  diseases  have  a  tendency  to  bring  about 
the  death  of  the  child  and  its  subsequent  expulsion  from  the  uterus.  The 
fatal  result  is  usually  due  to  the  transmission  of  toxines,  and  occasionally  of 
the  specific  micro-organisms  from  the  mother  to  the  child.  Poisoning  with 
phosphorus,  lead,  illuminating  gas,  and  other  substances  may  lead  to  simi- 
lar "resurTs^ 

Diseases  of  the  heart  and  kidneys  may  likewise  play  a  jDrominent  part  in 
the  causation  of  foetal  death,  in  the  former  it  is  attributed  to  imperfect 
aeration  of  the  blood;  in  the  latter  it  may  result  directly  from  the  accumula- 
tion of  excrementitious  substances  in  the  maternal  blood  and  their  subse- 
quent transmission  to  the  foetus;  or  indirectly,  from  the  fact  that  large 
portions  of  the  placenta  are  thrown  out  of  function  by  extensive  infarct 
formation.  Less  commonly  diseases  of  the  liver_or  lungs  of  the  mother  may 
be  indirectly  responsible. 

Foetal  death  is  sometimes  attributable  to  malnutrition. on  the  part  of  the 
mother,  although  this  is  very  exceptional.  On  the  other  hand,  it  is  not 
unusual  for  women  suffering  from  wasting  diseases  to  give  birth  to  fully 
developed  children. 

Abnormalities  in  the  generative  tract  likewise  play  an  important  part 
in  the~a^riology7tf  aboitTTm.  Thus,  developmental  anomalies  of  the  uterus, 
or  imperfect  development  of  the  normally  formed  organ,  may  be  responsible 
for  conditions  which  are  unfavourable  for  the  implantation  of  the  ovum  and 
later  for  the  development  of  the  placental  circulation.  Chrome  metritis  is 
also  supposed  to  act  in  the  same  way.    Dense  adhesions  about  the  tubes  and 


ABORTION.   MISCAKKIACK.   AND    PREMATURE    LABOUB  523 

ovaries,  resulting  from  inflammatory  processes,  only  rarely  interfere  with 
the  expansion  of  the  uterus  sufficiently  to  give  rise  to  abortion,  since  in 
most  cases  the  bands  of  adhesions  gradually  stretch  and  become  <•!< moated. 

Displacements  of  the  uterus,  more  particularly  retroflexion  and  pro- 
lapse/are  jusTry-crrrisulerecl  as  mo*st  important  factors  in  the  causation  of 
abortion.  As  a  rule,  the  interruption  of  pregnancy  is  due  less  to  the  ab- 
normal position  of  the  uterus  than  to  changes  in  its  endometrium  incidenl 
to  the  displacement.  In  the  rare  cases  of  incarceration,  however,  the  acci- 
dent must  he  attributed  to  the  persistent  abnormal  position  of  the  organ. 

The  most  important  factor  in  the  production  of  abortion  is  afforded  by 
diseases  and  abnormalities  of  the  decidua.  In  the  hypertrophic  forms  of 
decidual  endometritis — decidua  polyposa: — the  bulk  of  the  maternal  blood 
brought  to  the  placental  site  goes  to  nourish  the  hyperplastic  decidua,  while 
in  the  atrophic  forms  the  conditions  are  unfavourable  for  the  normal  im- 
plantation of  the  ovum  and  the  development  of  the  placenta.  More  impor- 
tant still  is  the  part  played  by  chronic  glandular  endometritis  and  acute 
inflammation  of  the  decidua.  The  former  is  usually  accompanied  by  hemor- 
rhagic changes,  and  is  the  most  frequent  cause  of  abortion  in  the  early/ 
months.  The  presence  of  myomata  in  the  walls  of  the  uterus  must  be/ 
looked  upon  as  an  occasional  factor,  abortion  resulting  less  from  the  me- 
chanical effect  of  the  tumour  itself  than  from  the  changes  in  the  decidua 
incident  to  it. 

In  a  few  cases  the  cause  of  abortion  is  to  be  sought  for  in  reflex  influ- 
ences  which  take  their  origin  from  lesions  of  the  generative  tract  or  from 
irritative  conditions  about  the  breasts.  In  very  rare  instances  the  accident 
is  attributable  to  intense  mental  emotions — anger,  fright,  or  grief. 

It  is  customary  to  distinguish  between  predisposing  and  exciting  causes 
of  abortion.  The  various  factors  to  which  allusion  has  just  been  made, 
predispose  to  abortion,  while  the  exciting  cause  is  often  of  a  mechanical 
nature,  such  as  a  slight  fall,  iar.  or  overexertion.    The  statements  of  the 

>-2 ,    rf 

patient  concerning  the  latter,  however,  must  be  received  with  caution,  as 
in  many  cases  they  are  merely  incidental  and  have  no  connection  with  the 
interruption  of  pregnancy.    At  the  same  time  it  must  be  admitted  that  the 
apparently  healthy  uterus  in  certain  women  possesses  an  abnormal  degree 
of  irritability,  and  will  react  to  stimuli  which  in  others  would  be  without 
effect.     In  such  patients  the  slightest  violence,  such  as  coitus,  a  misstep,  . 
tripping  over  a  carpet,  or  a  ride  over  a  rough  road  may  bring  on  an  abortion;  \ 
while  in  others  the  most  violent  exercise  and  the  rudest  manipulations  may  ( 
be  borne  with  impunity.    Occasionally  a  simple  bimanual  examination  may 
be  followed  by  an  abortion;  while,  on  the  other  hand,  every  physician  can 
recall  cases  in  which  a  sound  has  been  introduced  into  the  pregnant  uterus 
without  ill  effects,  and  in  rare  instances,  in  the  later  months,  the  repeated 
introduction  of  a  large  bougie,  or  even  of  a  Champetier  de  Eibes  balloon, 
will  fail  to  bring  about  satisfactory  uterine  contractions. 

(c)  Practically  the  only  paternal  cause  of  abortion  is  syphilis,  which,  as 
has  already  been  said,  frequently  leads  to  changes  in  the  placenta  and 
the  organs  of  the  foetus,  which  bring  about  its  death  and  its  premature 
expulsion  from  the  uterus. 


524 


OBSTETRICS 


To  sum  up,  the  most  important  serological  factors  in  the  interruption  of 
pregnancy  in  the  first  four  months  are  enrlometT-ifis  and  uterine  displace- 
ments, while  after  this  period  syphilis  and  Bright's  disease  play  a  similar 
rdle.  Thus,  Sentex,  in  485  cases  of  intra-uterine  death  occurring  in  the 
later  months  of  pregnancy  in  Pinard's  clinic,  found  the  underlying  cause  to 
be  syphilis  in  42.7,  albuminuria  in  19.8,  and  diseases  and  abnormalities  of 
the  foetus  in  11.1  per  cent. 

It  is  not  unusual  to  meet  with  women  who  give  a  history  of  repeated 
abortion  or  premature  labour  occurring  at  about  the  same  time  in  a  number 
of  successive  pregnancies.  Careful  examination  of  such  patients  will 
usually  demonstrate  the  existence  of  an  endometritis  or  a  uterine  displace- 
ment, if  the  interruption  has  occurred  in  the  first  half  of  pregnancy;  and  it 
is  only  after  the  cure  of  the  underlying  condition  that  subsequent  preg- 
nancies can  be  expected  to  progress  to  full  term.  When  repeated  prema- 
ture labour  has  occurred  in  the  second  half  of  gestation,  signs  of  albuminu- 
ria, Bright's  disease,  or  syphilis  will  usually  be  discovered.  This  subject 
haTrecently  been  considered  m  detail  by  Lomer. 

Pathology. — In  the  first  half  of  pregnancy,  the  immediate  cause  of  the 
expulsion  of  the  ovum  is  to  be  found  in  hamiorrhagic  changes  in  the  de- 
cidua.  Concerning  their  mode  of  production  we  must  confess  a  profound? 
ignorance,  although  when  endometritis  is  the  underlying  cause  their  origin 
is  readily  understood.  These  changes,  which  are  most  marked  in  the  cle- 
cidua  serotina,  are  followed  by  degeneration  of  the  affected  tissues,  as  the 
result  of  which  the  attachment  of  the  ovum  to  the 
uterine  wall  becomes  more  or  less  loosened,  and  the 
product  of  conception  comes  to  act  as  a  foreign  body 
and  gives  rise  to  uterine  contractions,  which,  after 
a  longer  or  shorter  period,  lead  to  its  expulsion. 

Sometimes,  especially  in  the  early  months,  the 
entire  ovum  may  be  expelled  after  a  few  premoni- 
tory symptoms,  and  not  infrequently  the  entire  de- 
cidual lining  of  the  uterine  cavity  is  cast  off  at  the 
same  time.  In  such  cases  a  triangular  sac  comes 
away  which  represents  the  decidua  vera  and  is  made 
up  of  blood-stained  tissue  several  millimetres  in 
thickness.  It  contains  in  its  interior  the  rounded 
vesicular  ovum,  covered  by  the  decidua  reflexa. 
More  frequently,  however,  the  decidua  vera  remains 
in  utero,  while  the  ovum,  surrounded  by  the  decidua 
reflexa,  is  expelled.  Occasionally  the  reflexa  is  torn 
through,  and  a  shaggy,  more  or  less  spherical  struc- 
ture is  cast  off — the  ovum  surrounded  by  the  chori- 
onic villi. 

As  pregnancy  advances,  the  expulsion  of  the 
entire  ovum  is  observed  less  frequently,  so  that 
after  the  fourth  month  it  is  the  rule  for  the  mem- 
branes to  rupture  and  the  foetus  to  be  expelled  by  itself,  followed  by  the 
placenta  and  membranes.     Occasionally  the  intact  ovum  may  be  expelled 


Fig.  406.  —  Early  Abor- 
tion, showing  Decidua 
Eeflexa  and  Serotina 
with  Degenerate  Em- 
bryo.    X  1. 


ABORTION'.    MISCAUIUAGE,   AND    PREMATURE    LABOUR 


525 


even  at  a  Later  period,  and  I  have  seen  several  cases  in  which  this  occurred 
as  late  as  the  seventh  or  eighth  month.  This,  however,  is  very  unusual, 
tli''  course  of  premature  labour  being  identical  with  that  observed  at 
full  term. 

In  many  instances  the  process  of  abortion  occurs  very  slowly,  so  that 
tlu'  blood  poured  out  between  the  periphery  of  the  ovum  and  the  decidua 
has  an  opportunity  to  coagulate.     Under  such  conditions,  the  ovum  on 


Fig.  467. — Tuberous  Subchorial  Hematoma  I  Breus).     X  1. 


its  expulsion  is  sitrrounded  by  a  capsule  of  Hotted  hloorl  of  varving  thick- 
ness with  degenerated  chorionic  villi  scattered  through  it.  In  its  interior 
is  a  small  cavity  rilled  with  clear  fluid  and  lined  by  a  thin,  glistening  mem- 
brane (the  amnion)  from  one  point  of  which  hangs  the  umbilical  cord 
and  the  partially  degenerated  foetus.  Such  structures  are  classified  as  blood 
or  carnpoiis  woIps.  according  to  their  appearance.  Inthe  former  the  capsule 
of  coagulated  blood  is  red  in  colour,  while  in  the  latter  it  presents  a  paler 
appearance,  the  result  of  fibrin  formation  (Fig.  468). 

]S  ow  and  then,  the  interior  of  such  structures,  instead  of  being  lined  by 
the  smooth  amnion,  may  present  an  irregular  nodular  appearance,  which  is 
due  to  the  formation  of  hamiatomata  of  varying  size  beneath  the  amnion 
and  chorion.     This  condition,  to  which  Granville  applied  the  term  ovum 


526  OBSTETRICS 

tuberculosum,  has  been  more  particularly  studied  by  Breus,  who  designated 
it  as  tuberous  subchorial  luematoma  of  the  decidua  (Fig.  467).  He  believed 
that  the  tuberous  appearance  was  the  result  of  haemorrhage  into  collapsed 
folds  of  the  amnion,  while  Gottschalk,  Walther,  and  others  considered  that 
the  haemorrhage  was  the  primary  factor.  Davidsohn,  in  a  recent  article,, 
takes  the  view  that  the  disproportion  between  the  size  of  the  foetus  and  the 
ovum  is  the  result  of  hydramnios,  and  after  the  death  of  the  former  the 
amniotic  fluid  is  gradually  absorbed,  when  the  redundant  amnion  becomes 
folded  upon  itself,  the  blood  being  effused  into  its  folds. 

Tn  all  ntm-inff  molps  the  foetus  is  relatively  smaller  in  size  than  would 
naturally  correspond  with  the  menstrual  history.    This  fact  indicates  that 

the  process  is  of  gradual  formation,  and 
Jjk  that  a  considei'able  period  elapses  between 

|  the  death  of  the  foetus  and  the  expulsion 

^l    ,       •■/■         i  ...  of  the  ovum.     Not  uncommonly,  indeed,. 

Vf*  >  •''^'Sb  the  foetus  may  undergo  complete  dissolu- 

tion,  or  be  represented  merely  by  a  stub 
of  umbilical  cord  hanging  from  the  interior 
of  the  ovum;  while  in  rare  instances  all 
trace  of  it  may  disappear,  and,  after  re- 
sorption of  the  amniotic  fluid,  the  ovum 
jjj  ^;|     may  be  represented  by  a  solid  mass  of  vary 

ing  size,  composed  of  chorionic  villi  em 
bedded  in  coagulated  blood. 

Dissolution,  of  the  dead  foetus  is  pos- 
sible only  in  the  early  weeks  of  pregnancy, 
and  cannot  occur  after  it  has  attained  any 
considerable  proportions.  In  the  latter 
class  of  cases  the  retained  foetus  may  un- 
™ ",  „0    c,  t,  dergo    maceration.      Under   such    circum- 

ilG.    468. bECTION   THROUGH    JjLOOD  -i  j-— — * 

Mole,    x  l.  stances  the  brain  degenerates,  the  bones 

of_the  skull  codlapse,  the  abdomen  becomes 

distended  with  a  blood-stained  fluid,  and  the  entire  foetus  takes  on  a  dull 


reddisli  colour  due  to  staining  with  blood  pigment.  At  the  same  time  the 
skinsoftens  and'  peels  off  at  the  slightest  touch,  leaving  behind  the 
bright-reel  corium.  The  internal  organs  become  soft  and  friable,  and 
lose  their  capacity  for  taking  up  the  usual  histological  stains.  In  rarer 
instances  the  foetus  becomes  compressed  and  takes  on  a  dry,  parchment- 
like appearance — mummification.  This  is  rarely  observed  in  ordinary  abor- 
tion, but  is  noted  with  comparative  frequency  in  twin  pregnancies,  when 
one  foetus  has  died  at  an  early  period  while  the  other  has  gone  on  to 
full  development — -foetus  papyraceus. 

In  very  exceptional  instances  the  foetus  may  be  retained  in  utero  for 
a  long  period,  until  the  deposition  of  lime  salts  upon  it  converts  it  into 
what  is  known  as  a  litlm^iRclimi .  This  phenomenon,  though  extremely  rare 
in  uterine  pregnancy  in  human  beings,  is  relatively  common  in  the  lower 
animals.  In  extrauterine  gestation,  on  the  other  hand,  such  a  condition 
is  not  of  unusual  occurrence. 


ABORTION,    MISCARRIAGE,    AND    PREMATURE    LABOUR  527 

Clinical  History. — From  a  clinical  standpoint  it  is  a  matter  of  consider- 
able importance  to  distinguish  the  period  at  which  the  pregnancy  is  ter- 
minated. When  it  occurs  in  the  first  half  it  is  not  unusual  for  the  ovum  to 
be  expelled  as  a  whole,  while  in  the  second  half  of  pregnancy  the  course  of 
events  is  similar  to  that  oljserved  at  a  full-tcrni'labour. 

The  onset  of  abortion  is  "usually  preceded  by  certain  premonitory  symp- 
toms, the"  most  important  ot  which  are  liifminTliiiyc  and  pain  in  the  back 
and  lower  abdomen.  Loss  of  blood,  no  matter  how  slight,  in  the  early 
months  of  pregnancy,  should  always  be  regarded  with  suspicion,  for  if  it  be 
not  a  premonitory  symptom  of  abortion  it  usually  indicates  the  existence  of 
a  hyperplastic  endometritis  or  an  abnormal  implantation  of  the  placenta. 
When  due  to  the  former  the  discharge  is  usually  not  very  profuse,  and  is  I 
of  a  dirty  brown  or  brownish-red  colour,  while  when  due  to  the  latter  it  is  J 
apt  to  be  more  profuse  and  distinctly  bloody  in  character.  The  premonitory 
bleeding  may  persist  for  weeks  or  be  promptly  followed  by  the  expulsion  of 
the  ovum.  Indeed,  in  some  cases  the  latter  event  may  occur  so  rapidly  as 
to  surprise  the  patient. 

When  a  patient  in  the  first  few  weeks  of  pregnancy  begins  to  lose  blood, 
and  the  flow  is  associated  with  pain  in  the  lower  abdomen  and  back,  an  *-^ 
abortion  is  threatened.  It,  however,  does  not  become  inwunent  unless  the 
haemorrhage  be  profuse  or  the  cervix  considerably  dilated;  even  in  the  latter 
case  it  is  not  impossible  for  the  disturbance  to  subside,  and  for  pregnancy 
to  go  on  without  interruption.  On  the  other  hand,  rupture  of  the  mem-  -^ 
branes  and  escape  of  the  liquor  amnii  indicate  that  abortion  is  inevitable. 

when  abortion  becomes  imminent,  the  haemorrhage  is  usually  quite  pro- 
fuse, though  as  a  rule  not  sufficient  to  endanger  the  life  of  the  woman. 
At  the  same  time  she  experiences  severe  cramp-like  pains  in  the  abdomen 
due  to  the  uterine  contractions,  which  later  become  distinctly  bearing-down 
in  character.  After  the  cervix  has  become  sufficiently  dilated  the  detached 
ovum  may  be  expelled  intact  from  the  uterus,  and  when  not  retained  in  the 
vagina  comes  away  satisfactorily.     This  is  known  as  complete  abortion.  X. 

Xot  uncommonly,  on  the  other  hand,  after  rupture  of  the  membranes 
and  the  escape  of  the  amniotic  fluid,  the  foetus  alone  is  expelled,  while  the 
placenta  and  membranes  remain  in  the  uterus — incomplete  abortion.  In  X 
such  cases  the  haemorrhage  usually  persists  until  the  retained  structures 
are  extruded  spontaneously  or  are  removed  artificially,  though  the  pains 
usually  cease  with  the  expulsion  of  the  foetus.  After  the  uterus  has  rid 
itself  of  the  product  of  conception,  the  haemorrhage  and  pain  cease,  and  a 
process  of  involution  begins,  identical  with  that  observed  after  full-term 
labour. 

Treatment. — Prophylactic  treatment  is  most  important,  although,  as 
a  rule,  it  is  not  available  in  women  aborting  for  the  first  time.  If.  how- 
ever, the  patient  presents  a  history  of  repeated  abortion  or  premature  la- 
bour, precautionary  measures  should  be  instituted  before  conception  has 
again  taken  place. 

The  general  and  local  condition  should  be  carefully  investigated  and 
any  abnormality  subjected  to  appropriate  treatment.  If  the  patient  has  a 
retroflexed  uterus,  the  organ  should  be  replaced  and  held  in  position  by 


528  OBSTETRICS 

a  properly  fitting  pessary.  If  the  desired  results  are  not  obtained  in  this 
way,  ventrosuspension  or  some  other  suitable  operation  should  be  performed. 
If  endometritis  be  present,  the  patient  should  be  curetted  and  warned 
against  becoming  pregnant  until  sufficient  time  has  "elapsed  to  allow  the 
uterus  to  recover  from  the  morbid  condition.  If  the  symptoms  reappear, 
the  operation  should  be  repeated.  If  there  is  no  abnormality  in  the 
generative  tract,  the  possibility  of  syphilis  in  either  parent  should  be  borne 
in  mind,  and  appropriate  treatment  instituted  in  suspicious  cases.  The 
urine  should  always  be  carefully  examined  with  a  view  to  determining  the 
presence  or  absence  of  renal  lesions. 

If  past  experience  has  shown  that  the  patient  has  an  irritable  uterus 
and  is  predisposed  to  abort  upon  the  slightest  provocation,  coitus  should 
be  interdicted  during  pregnancy,  and  the  patient  be  cautioned  against  over- 
exertion and  encouraged  to  lead  a  careful,  well-ordered  existence.  More- 
over, she  should  be  instructed  to  take  to  her  bed  immediately  upon  the  ap- 
pearance of  any  untoward  symptom. 

Treatment  of  Threatened  Abortion. — Whenever  symptoms  of  threatened 

ft.  j<   abortion  appear,  the  patient  should  be  placed  in  bed  and  kept  in  a  recum- 
bent position.     If  pains  occur,  a  hypodermic  injection  of  \  grain  of  mor- 
phine should  be  administered  at  once,  to  be  followed  by  1-gram  rectal  sup- 
JM^ositories  of  extract  of  ophrm.  repeated  at  intervals  of  every  four  or  six 

-A  hours.  Better  results  are  occasionally  obtained  by  combining  the  opium 
with  the  extracts  of  hyoscyamus  and  viburnum  prunifolium.  The  following 
suppository,  administered  every  four  or  six  hours,  according  to  circum- 
stances, often  gives  most  satisfactory  results: 

5  •     Codias  sulphat gr.  ss. 

Ext.  hyoscyami gr.  j. 

Ext.  viburni  prunifolii gr.  v. 

01.  theobroma? q.  s. 

In  many  instances  the  symptoms  rapidly  subside  under  such  treatment, 
but  the  patient  should  be  kept  in  bed  for  at  least  a  week  after  their  disap- 
pearance, in  the  hope  of  avoiding  any  repetition. 

I        In  other  cases,  the  pain  yields  to  the  administration  of  sedatives,  but 
J  the  haemorrhage  persists,  and  we  then  have  to  decide  how  long  we  are  justi- 
I  fied  in  permitting  the  bloody  uterine  discharge  to  continue,  and  whether 
'  there  is  any  probability  that  an  interruption  of  pregnancy  will  not  occur. 
So  long  as  the  loss  of  blood  does  not  exceed  that  usually  observed  at 
the  menstrual  period,  the  flow  is  not  necessarily  incompatible  with  the 
continuance  of  pregnancy,  and  may  be  permitted  to  go  on  for  some  time. 
On  the  other  hand,  if  it  becomes  so  profuse  that  the  patient  begins  to  show 
signs  of  anaemia,  the  uterus  should  be  emptied  by  the  methods  to  be  de- 
scribed later.     In  many  instances,  notwithstanding  appropriate  treatment 
and  rest  in  bed,  slight  haemorrhage  may  persist  for  several  weeks,  and  it 
then  becomes  necessary  to  ascertain  whether  there  is  any  possibility  of  the 
pregnancy  continuing.     Unfortunately,  this  problem  usually  requires  sev- 
eral weeks  for  its  solution.     Thus,  if  bimanual  examination  shows  at  the 
end  of  two  weeks  that  the  uterus  has  remained  stationary  in  size,  one  is 
justified  in  concluding  that  the  foetus  has  perished;  while,  on  the  other 


ABORTION,    MISCARRIAGE,   AND   PREMATURE   LABOUR  529 

hand,  an  increase  probably  indicates  that  the  foetus  is  still  alive,  but  does 
not  necessarily  mean  that  pregnancy  will  go  on  to  a  happy  termination. 
As  soon  as  we  are  convinced  that  the  foetus  is  dead,  the  uterus  should  be 
promptly  emptied.  In  such  cases  nothing  can  be  gained  by  delay,  as  abor- 
tion  will  inevitably  occur  sooner  or  later,  whereas  temporizing  treatment 
sometimes  exposes  the  patient  to  serious  danger. 

Treatment  <>f  Inevitable  Abortion.— When  convinced  that  abortion  is  in- 
evitable, particularlym  those  eases  in  which  the  haemorrhage  is  profuse, 
the  uterus  should  be  emptied  in  the  most  conservative  manner,  the  choice 
of  procedure  depending  upon  the  degree  of  dilatation  of  the  cervix.  If  it 
be  sufficiently  patulous  to  admit  one  or  two  fingers,  the  patient  should  be 
anaesthetized,  brought  to  the  edge  of  the  bed,  and  prepared  for  operation. 
The  carefully  sterilized  hand,  anointed  with  sterile  vaseline,  having  been 
introduced  into  the  vagina,  one  or  preferably  two  fingers  are  carried  up 
into  the  uterine  cavity,  and  under  the  guidance  of  the  other  hand  applied 
over  the  abdomen,  peeloff  the  ovum  from  the  uterine  wall  and  slowly 
extract  it.  If  this  cannot  be  effected  the  ovum  should  be  broken  up  by  the 
finger  and  the  fragments  extracted  by  means  of  a  placental  or  ovum  for-  ) 
ceps,  under  the  guidance  of  a  finger  within  the  uterus. 

But  if.  as  often  happens,  the  cervix  is  not  sufficiently  dilated  to  permit 
the  introduction  of  a  finger,  the  cervical  canal  and  vagina  should  be  packed 
tightly  with  a  sterile  gauze  bandage,  as  described  in  Chapter  XXIV,  and 
30  drops  of  the  fluid  extract  of  ergot  administered  every  four  hours.  When 
removed  at  the  end  of  twenty-four  hours,  the  pack  frequently  brings  with 
it  the  intact  ovum:  but,  even  if  this  does  not  occur,  the  cervix  will  generally 
be  sufficiently  dilated  to  permit  the  introduction  of  the  finger,  when  the 
ovum  can  be  removed  as  recommended  above. 

This  method  of  procedure  is  preferable  to  the  rapid  dilatation  of  the 
cervix  with  a  Goodell  or  some  similar  dilator,  followed  by  the  immediate 
removal  of  the  ovum  by  means  of  a  curette  or  polypus  forceps.  Moreover, 
the  cervix  is  sometimes  so  resistant  that  it  is  impossible  to  dilate  it  suffi- 
cientlv  by  means  of  metallic  dilators  to  permit  the  introduction  of  the 
finger,  the  employment  of  which,  in  my  opinion,  is  essential  for  the  proper 
evacuation  of  the  uterus  and  a  careful  exploration  of  its  cavity  after  removal 
of  the  ovum,  in  order  to  make  sure  that  it  is  perfectly  empty,  and  that  there 
is  consequently  no  danger  of  subsequent  haemorrhage. 

Xo  doubt  the  uterus  can  be  satisfactorily  evacuated  in  most  cases  by 
means  of  the  curette  and  polypus  forceps,  but  no  instrument  has  ever  been 
invented  which  will  prove  an  efficient  substitute  for  the  carefully  trained 
sense  of  touch  when  it  becomes  necessary  to  satisfy  one's  self  that  no  rem- 
nants of  the  ovum  are  still  retained  in  the  uterus.  On  several  occasions 
I  have  seen  patients  suffering  from  profuse  haemorrhage  following  the 
supposed  thorough  removal  of  the  product  of  conception  by  curetting,  and, 
on  introducing  the  finger  into  the  uterus.  I  have  found  that  it  still  con- 
tained the  bulk  of  the  ovum.  Experiences  of  this  kind  have  therefore  led 
me  to  do  away  with  the  use  of  instruments  except  in  very  rare  cases. 
Moreover,  in  addition  to  the  fact  that  they  fulfil  their  object  only  imper- 
fectly, they  are  not  devoid  of  dansrer.    Every  orvnaeeolosfist  is  familiar  with 


.■  &j 


530  OBSTETRICS 

cases  in  which  the  softened  uterus  has  been  perforated  by  the  curette,  and 
knows  of  rare  instances  in  which  a  loop  of  gut  has  prolapsed  through  the 
opening  so  made. 

When  the  ovum  has  been  expelled  intact,  as  in  complete  abortion,  there 
is  no  necessity  for  further  interference;  and,  as  a  rule,  if  the  decidua  vera 
is  not  cast  off,  it  is  not  advisable  to  attempt  its  removal  by  means  of  the 
curette,  for  it  is  usually  expelled  spontaneously  within  a  few  days.  At  the 
same  time  the  physician  should  always  satisfy  himself  by  careful  inspection 
that  the  entire  ovum  has  come  away,  and  that  portions  of  it  are  not  re- 
tained. In  incomplete  abortion,  on  the  other  hand,  the  retained  placenta 
and  membranes  should  be  removed  manually  by  the  methods  already  de- 
scribed.As  soon  as  the  uterus  is  emptied  it  contracts  and  the  danger  of 
haemorrhage  has  passed. 

It  often  happens  that  the  physician  does  not  see  the  patient  until  some 
days  after  the  expulsion  of  the  foetus,  when  the  cervix  has  retracted  to 
such  a  degree  that  it  will  not  admit  the  finger.  Under  these  circumstances 
it  can  readily  be  sufficiently  dilated  by  means  of  a  Goodell  dilator,  after 
which  the  remnants  of  the  ovum  are  removed  by  the  finger.  In  other  cases 
infection  has  resulted,  and  the  uterine  discharge  may  be  very  foul-smelling. 
In  such  cases  the  cervix  should  be  dilated  and  the  uterus,  after  being, 
emptied,  should  be  washed  out  with  an  abundance  of  sterile  salt  solution. 
If  the  symptoms  still  persist  after  this  procedure,  the  uterine  wall  has  been 
invaded  by  the  offending  micro-organisms,  and  we  have  to  deal  with  a 
case  of  puerperal  infection,  the  treatment  of  which  is  considered  in  the 
appropriate  chapter. 

The  treatment  of  abortion  in  the  second  half  of  pregnancy  and  of  pre- 
mature labour  is  identical  with  that  already  described  for  full-term  labour, 
and  does  not  require  further  mention. 

Missed  Abortion. — This  term  was  applied  by  Oldham  to  the  rare  cases 
in  which  the  foetus  is  retained  in  the  uterine  cavity  for  months  or  even 
years  after  its  death.  Eetention  may  exist  for  a  long  period  without  giving 
rise  to  symptoms,  and  this  possibility  should  always  be  borne  in  mind  in 
the  case  of  an  abortion  occurring  in  a  woman  who  has  been  for  some  time 
separated  from  her  husband,  inasmuch  as  an  error  in  this  regard  occasionally 
results  in  irreparable  damage  to  her  character.  In  other  cases  the  patient 
may  believe  herself  to  be  in  the  seventh  or  eighth  month,  and  yet  on 
examination  the  uterus  will  be  found  to  correspond  in  size  to  that  of  a 
three-months'  pregnancy.  Seventy  instances  of  this  kind  have  been  col- 
lected by  Graefe,  11  of  the  cases  having  been  seen  by  him,  and  the  rest 
having  been  recorded  in  the  literature.  In  epiite  a  number  the  foetus 
had  been  retained  for  more  than  a  year,  and  in  one  instance  for  twenty- 
eight  }rears. 

According  to  Veit  and  Graefe,  the  retention  is  to  be  attributed  to  a 
lack  of  irritability  on  the  part  of  the  uterus,  which  does  not  contract  as 
usual  under  tlie  stimulation  excited  by  the  dead  ovum  acting  as  a  foreign 
body.  Not  uncommonly  the  condition,  after  persisting  for  some  time 
without  symptoms,  may  exert  an  appreciable  effect  upon  the  patient,  who 
may  suddenly  begin  to  lose  flesh,  suffer  from  a  foul  taste  in  her  mouth, 


ABORTION,    MISCARRIAGE,   AND    PREMATURE   LABOUR  531 

perhaps  present  a  slight  elevation  of  temperature,  and  occasionally  manifest 
symptoms  of  mental  derangement. 

Whenever  the  diagnosis  is  established  beyond  doubt,  the  cervix  should 
be  dilated  by  means  of  n  vaginal  and  cervical  pack,  and  the  uterus  emptied 
of  its  contents.  In  several  instances  under  my  observation  the  cervix  was 
so  resistant  thai  its  dilatation  by  means  of  steel  instruments  was  oat  of  the 
question. 

LITERATURE 

Breus.     Das  tuberose  subchoriale  Ilaematom  der  Decidua.     Leipzig  u.  Wien,  1892. 
Davidsohn.     Zur  Lehre  von  der  Mola  haematomatosa.     Archiv  f.  Gyn.,  1902,  lxv,  181- 
216. 

I-'kano.ue.     Ueber  histologische  Veranderungen  in  der  Placenta  und  ihre  Beziehungen 

zum  Tode  der  Frucht.     Zeitschr.  f.  Geb.  u.  Gyn.,  1897.  xxxvii,  277-298. 
Franz.     Zur  Lehre  des  Aborts.     Hegar's  Beitrage,  1898,  i,  493-514. 
Gottschalk.     Zur  Lehre  von  den   Hamatommolen,  etc.      Archiv  f.  Gyn.,  1899,  xviii, 

134-169. 
Graefe.     Ueber  Retention  des  menschlichen  Eies  im  Uterus  nach  dem  Fruchttod.    Fest- 

sclirift  zu  Carl  Ruge,  Berlin,  1896,  38-79. 
Granville.     Graphic  Illustrations  of  Abortion,  etc.     London,  1834. 
Lomer.     Zur  Therapie  wiederholter  Aborte  und  der  Fruhgeburt  todter  Kinder.    Zeitschr. 

f.  Geb.  u.  Gyn.,  1901,  xlvi.  282-306. 
Merttens.    Beitrage   zur  normalen  und   path.  Anatomie  der  menschlichen   Placenta. 

Zeitschr.  f.  Geb.  u.  Gyn.,  1894.  xxx,  1-97. 
Oldham.     Missed  Labour.     Guy's  Hosp.  Reports,  1847,  105-112. 
Sentex.     Des  causes  de  la  mort  du  produit  de  la  conception  pendant  la  grossesse.     These 

de  Paris,  1901. 
Veit.    Vorzeitige  Unterbrechung  der  Schwangerschaft.     Miiller's  Handbuch  der  Geburts- 

hiilfe,  1889,  ii,  23-57. 
Walther.    Ein  Fall  von  tuberosem,  subchorialem  Hamatom  der  Decidua.     Centralbl.  f. 

Gyn.,  1892,  707-710. 


35 


CHAPTEE  XXX 
EXTRA-UTERINE  PREGNANCY 

In  extraruteriij&jvregnancyjhe  fertilized  ovum  is  arrested  at  some  point 
between  the  ovary  and  the  uterus,  and  there  undergoes  more  or  less  com- 
plete development.  Ectopic  gestation,  which  is  sometimes  used  as  a  synon- 
ymous term,  has  a  broader  meaning,  inasmuch  as  it  includes  not  only  the 
usual  forms  of  extra-uterine  pregnancy,  but  also  those  in  which  the  ovum 
is  implanted  in  the  rudimentary  horn  of  a  bicornuate  uterus.  Reference  has 
already  been  made  to  this  class  of  cases  in  Chapter  XXVII. 

For  a  long  time  extra-uterine  pregnancy  was  of  interest  chiefly  from  a 
pathological  point  of  view,  but  since  1883,  when  Tait  first  operated  upon 
a  case  of  ruptured  tubal  pregnancy,  the  subject  has  attained  a  markedly 
practical  interest,  as  is  manifested  by  the  immense  literature  of  recent 
years.  The  history  of  its  development  is  treated  in  detail  in  the  mono- 
graphs of  Campbell,  Hecker,  Parry,  Tait,  Werth,  and  Webster. 

Prior  to  1876,  extra-uterine  pregnancy  was  considered  so  rare  an  affec- 
tion that  Hennig  stated  that  even  the  directors  of  large  obstetrical  insti- 
tutions might  never  encounter  a  case,  and  Parry  was  able  to  collect  only 
500  instances  from  the  entire  literature.  It  was  only  with  the  gradual  de- 
velopment of  abdominal  surgery  that  its  relative  frequency  became  recog- 
nised. Thus  Schrenck,  in  1892,  collected  610  cases  which  had  been  re- 
ported in  the  preceding  five  years,  and  recently  many  operators  have  placed 
on  record  large  series,  Kiistner  having  operated  upon  105  cases  in  the 
course  of  five  years,  while  Noble  encountered  extra-uterine  pregnancy  in 
from  3  to  4  per  cent  of  all  his  laparotomies. 

JEtiology. — Unfortunately,  concise  and  definite  statements  cannot  be 
made  concerning  the  aetiology  of  the  condition,  although  quite  a  number  of 
explanations,  of  greater  or  less  plausibility,  have  been  advanced.  Broadly 
speaking,  these  may  be  divided  into  three  main  groups:  (1)  Conditions 
which  interfere  mechanically  with  the  downward  passage  of  the  ovum;  (2) 
Those  resulting  from  inflammatory  diseases  of  the  tubes,  ovaries,  and  pelvic 
peritonaeum;  (3)  Physical  and  developmental  abnormalities  which  favour 
decidual  formation  in  the  tubes. 

I.  Conditions  which  Interfere  Mechanically  with  the  Downward  Passage 
of  the  Ovum. — (a)  Pritze,  in  1779,  first  directed  attention  to  the  fact  that 
peritoneal  adhesions,  by  compressing  the  lumen  of  the  tube  or  by  inter- 
fering with  its  peristalsis,  might  cause  the  arrest  of  the  ovum. 
532 


EXTRA   UTERINE  PREGNANCY  .".:;:; 

(h)  Leopold,  Breslau,  Beck,  Wyder,  and  others  have  reported  cases  in 
which  they  believed  that  polypi  projecting  into  the  lumen  of  the  tube 
had  interfered  with  the  descent  of  the  ovum.  It  is  quite  possible,  however, 
(hat  such  structures  were  merely  decidual  outgrowths,  and  appeared  only 
after  concept  ion. 

(c)  Some  observers  believe  that  myomata  or  other  tumours,  situated 
in  the  wall  of  the  tube  or  in  adjacent  organs,  may  so  compress  the  tubal 
lumen  as  to  interfere  with  the  passage  of  the  ovum. 

(d)  Schroeder,  in  1887,  but  more  particularly  Tait,  a  few  years  later, 
advanced  the  theory  that  the  most  frequent  cause  of  tubal  pregnancy  was 
an  endosalpingitis,  whence  had  resulted  the  destruction  of  the  cilia,  and  the 
consequent  cessation  of  the  downward  current  which  was  thought  to  pre- 
vent the  entry  of  spermatozoa  into  the  tube. 

This  view  presupposed  that  fertilization  occurred  in  the  uterine  cavity, 
and  was  based  upon  the  belief  that  the  ciliary  current  was  directed  down- 
ward in  the  tubes  and  from  below  upward  in  the  uterus,  the  entry  of 
spermatozoa  into  the  uterine  cavity  being  thereby  facilitated,  while  their 
access  to  the  tubes  was  rendered  very  difficult.  The  recent  work  of 
Hofmeier  and  Mandl  has  demonstrated  the  fallacy  of  these  suppositions. 
Moreover,  animal  experiments  and  a  few  observations  upon  human  beings 
make  it  reasonably  certain  that  fertilization  occurs  normally  in  the  tubes, 
every  pregnancy  being  therefore  primarily  tubal.  Accordingly,  the  prob- 
lem to  be  solved  in  a  case  of  extra-uterine  pregnancy  is  not  how  the  sper- 
matozoa may  have  gained  access  to  the  tubes,  but  why  the  fertilized  ovum 
failed  to  make  its  way  to  the  uterus. 

Tait's  theory  found  many  adherents,  but  careful  study  of  specimens  ob- 
tained at  operation  go  to  show  that  in  most  cases  it  is  without  foundation. 

I  have  been  able  to- demonstrate  the  presence  of  cilia  in  nearly  every 
pregnant  tube  which  I  have  examined,  while  Zedel  saw  them  in  motion  in 
three  out  of  four  specimens  which  he  examined  in  the  fresh  condition. 

(e)  Abel,  Kreisch,  and  others  believe  that  the  foetal  convolutions  of 
the  tube  occasionally  persist  in  later  life,  and  hinder  the  downward  passage 
of  the  fertilized  ovum  either  by  constricting  the  lumen  or  by  interfering 
with  peristalsis. 

(f)  In  1891  Landau  and  Kheinstein  and  the  writer  demonstrated  the 
presence  of  diverticula  from  the  lumen  of  the  tube,  and  suggested  that  a 
fertilized  ovum  entering  such  a  structure  would  eventually  be  arrested  at  its 
blind  end,  and  there  might  undergo  further  development  (Fig.  469).  For 
a  number  of  years  I  believed  that  a  considerable  number  of  my  cases  had 
originated  in  this  way.  In  such  specimens  the  foetal  sac  lay  entirely  outside 
of  the  lumen  of  the  tube,  being  separated  from  it  by  a  layer  of  tissue  of 
varying  thickness  (see  Fig.  482).  After  further  examination  of  my  speci- 
mens, while  not  wishing  to  deny  such  a  possibility,  I  am  of  the  opinion  that 
these  conditions  can  be  more  satisfactorily  explained  by  supposing  that  the 
fertilized  ovum  had  burrowed  beneath  the  mucosa  of  the  tube,  just  as  it 
does  into  the  decidua  in  uterine  pregnancv. 

Now  and  again,  in  serial  sections  through  the  pregnant  tube,  it  is  possi- 
ble to  demonstrate  the  presence  of  accessory  lumina — long  processes  which 


534 


OBSTETRICS 


extend  from  the  main  lumen  and  continue  parallel  to  it  for  a  considerable 
distance,  and  then  rejoin  it  or  end  blindly.  I  have  noted  such  a  condition 
in  several  instances,  and  see  no  reason  why  a  fertilized  ovum  arrested  in 
such  a  structure  should  not  go  on  to  further  development. 


< 


m 


^ 


'     :» 


Fig.  469. — Diverticulum  from  the  Lumen  of  Tube. 

Sometimes  accessory  tubal  ostia,  instead  of  communicating  with  the 
lumen  of  the  tube,  represent  mere  culs-de-sac.  That  the  fertilized  ovum 
may  be  arrested  in  such  a  structure  and  go  on  to  further  development  was 
conclusively  demonstrated  by  Henrotin  and  Herzog  (Fig.  470). 


w 


Fig.  470. — Pregnancy  in  Accessory  Tubal  Ostium  (Henrotin  and  Herzog). 
A,  small  accessory  ostium;  B,  opening  of  pregnant  ostium;  C,  blind  end  of  same;  D,  blood-clot 

containing  remnants  of  ovum. 

(g)  Diihrssen  believes  that  in  occasional  instances  the  arrest  of  the  ovum 
may  be  due  to  puerperal  atrophy  of  the  tube,  whereby  its  normal  peristalsis 
is  markedly  impaired. 

(Ii)  In  a  considerable  number  of  the  cases  which  I  have  examined,  the 


EXTRA-UTERINE   PREGNANCY  535 

corpus  hit  cum  was  situated  not  in  the  ovary  corresponding  to  the  preg- 
nant tube,  but  in  the  opposite  one,  indicating  that  external  migration  had 
occurred,  and  that  the  fertilized  ovum  had  made  the  transit  of  the  pelvic 
cavity.  Sippel  helieves  that  such  a  phenomenon  may  favour  the  production 
of  extra-uterine  pregnancy,  since  the  fertilized  ovum  may  attain  such  pro- 
portions during  its  migration  as  to  prevent  its  passage  through  the  tube. 

IL  Conditions  resulting  from  Inflammatory  Conditions  of  the  Tubes, 
Ovaries,  and  Pelvic  Peritonceum. — As  has  already  been  said,  Schroeder  and 
Tait  pointed  out  that  such  conditions  may  result  in  the  production  of  tubal 
pregnancy.  This  view  is  supported  by  the  fact  that  many  cases  of  extra- 
uterine pregnancy  have  been  preceded  by  pelvic  inflammatory  trouble. 
Thus  Diihrssen,  Mandl  and  Schmidt,  Kustner,  and  others  were  aide  to 
elicit  a  history  of  gonorrhceal  salpingitis  or  inflammatory  conditions  of  the 
appendages  in  more  than  two  thirds  of  their  cases.  Martin  was  formerly 
an  enthusiastic  advocate  of  this  view,  but  has  recently  abandoned  it,  and 
now  considers  that  extra-uterine  pregnancy  is  nearly  always  the  result  of 
mechanical  interference  with  the  downward  passage  of  the  ovum. 

III.  Physical  and  Developmental  Conditions  which  Favour  Decidual  For- 
mation in  the  Tidies. — Webster  believes  that  the  explanation  for  the  com- 
paratively infrequent  occurrence  of  extra-uterine  pregnancy  is  to  be 
found  in  the  fact  that  the  decidual  reaction,  which  he  considers  essential  to 
the  proper  implantation  of  the  fertilized  ovum,  readily  occurs  in  the  uterus, 
but  is  usually  lacking  in  the  tubes.  He  holds  that  tubal  pregnancy  can 
come  about  only  when  the  tubes  are  capable  of  this  reaction.  Further- 
more, he  considers  that  such  an  occurrence  probably  represents  a  reversion 
to  an  earlier  type,  and  may  therefore  be  looked  upon  as  a  sign  of  degeneracy. 
This  view  was  soon  indorsed  by  Pantellani,  Mandl  and  Schmidt,  Wormser, 
Moericke,  and  others,  but  their  belief  was  based  upon  theoretical  considera- 
tions rather  than  upon  anatomical  facts. 

That  Webster's  theory  is  not  entirely  without  foundation  is  rendered 
probable  by  the  experimental  work  of  Tainturier  and  Mandl  and  Schmidt. 
in  which  an  artificial  obstruction  was  produced  in  the  generative  tract  of 
rabbits  by  applying  ligatures  to  one  or  both  sides  at  a  certain  period  of  time 
after  copulation.  When  these  were  placed  about  the  middle  of  the  cornua. 
ova  were  arrested  above  them  and  went  on  to  development;  but  when  the 
uterine  ends  of  the  tubes  themselves  were  ligated  extra-uterine  pregnancy 
never  occurred,  notwithstanding  the  fact  that  in  rare  instances  degenerated 
ova  could  be  demonstrated  above  the  ligatures.  In  a  control  series  Of  experi- 
ments, in  which  the  uterine  end  of  only  one  tube  was  ligated,  pregnancy 
occurred  in  the  non-ligated,  but  not  in  the  ligated  uterine  horn,  thus  show- 
ing that  the  experiment  had  been  performed  at  the  proper  time.  These 
observers,  therefore,  concluded  that  something  more  than  a  mere  mechanical 
obstruction  was  necessary,  and  believed  that  a  decidual  reaction  was  the 
essential  pre-requisite  for  the  production  of  tubal  pregnancy. 

In  the  presence  of  an  abundance  of  theories  concerning  the  aetiology 
of  extra-uterine  pregnancy,  it  still  remains  uncertain  which  of  them  is 
correct.  Theoretically,  it  would  appear  that  many  mechanical  conditions 
must  occasionally  play  a  part  in  the  production  of  the  abnormality;  but 


536  OBSTETRICS 

whereas,  certain  of  the  former  are  noted  with  considerable  frequency,  extra- 
uterine pregnancy  is  nevertheless  comparatively  rare. 

That  extra-uterine  pregnancy  is  dependent  upon  a  pre-existing  inflam- 
matory disease  of  the  generative  tract  cannot  be  demonstrated  in  the 
majority  of  cases,  since  in  many  instances,  as  in  the  43  cases  reported  by 
Taylor,  no  history  of  previous  inflammatory  disease  could  be  elicited.  More- 
over, even  when  such  lesions  are  noted,  it  still  remains  doubtful  whether 
they  existed  before  the  occurrence  of  pregnancy  or  were  secondary  to  it. 
Sutton  inclines  to  the  latter  view,  and  believes  that  the  occlusion  of  the  fim- 
briated end  of  the  tube,  which  is  so  often  noted,  is  the  result  of  the  preg- 
nancy itself. 

Nor  is  Webster's  decidual  reaction  theory  entirely  satisfactory,  since 
recent  histological  work  has  shown  that  the  decidua  does  not  play  nearly 
so  important  a  part  in  tubal  pregnancy  as  was  formerly  supposed,  many 
recent  authorities  going  so  far  as  to  deny  its  formation. 

The  idea  that  the  abnormality  is  a  sign  of  degeneracy  and  reversion, 
while  extremely  interesting  and  to  a  certain  extent  borne  out  by  facts, 
cannot  be  accepted  as  universally  true,  for  an  extra-uterine  pregnancy  some- 
times occurs  in  perfectly  healthy  women,  living  amid  the  very  best  sur- 
roundings. Moreover,  its  relative  infrequency  in  the  lower  animals  speaks 
against  such  a  view. 

Accordingly,  it  is  apparent  that  the  getiology  of  extra-uterine  preg- 
nancy is  not  a  simple  matter,  and  that  there  is  no  universal  cause.  As 
a  rule,  the  history  of  the  patient  and  a  careful  study  of  the  specimen 
will  afford  a  satisfactory  explanation  for  its  occurrence,  but  in  not  a 
few  instances  the  underlying  cause  will  remain  as  great  a  problem  to  us 
as  to  our  predecessors. 

Classification. — The  fertilized  ovum  may  be  arrested  at  any  point  on 
its  way  from  the  Graafian  follicle  to  the  uterine  cavity,  and  may  undergo 
development  in  the  ovary  or  in  any  portion  of  the  tube,  giving  rise  to 
ovarian  or  tubal  pregnancy  respectively.  It  is  extremely  doubtful  whether 
the  ovum  can  become  implanted  upon  the  peritoneum  and  a  primary 
abdominal  pregnancy  follow. 

Ovarian  Pregnancy  was  first  described  in  the  seventeenth  century,  by 
Mercerus  and  St.  Meurice,  after  which  it  was  generally  recognised  until 
1835,  when  Velpeau  stated  that  none  of  the  cases  which  had  been  described 
up  to  that  time  afforded  conclusive  evidence  of  ovarian  origin.  Similar 
views  were  expressed  by  Mayer  in  1847,  and  were  indorsed  by  Pouchet,  Allan 
Thompson,  and  others.  This  scepticism  was  probably  quite  justifiable  at 
the  time,  since  most  of  the  early  cases  collected  by  Campbell  and  Gurgui 
were  simply  dermoid  cysts  of  the  ovary. 

With  the  exception  of  Mayer,  the  possibility  of  ovarian  pregnancy  has 
always  been  admitted  by  the  German  writers,  but  was  strenuously  denied 
until  1901  by  the  English  authorities,  particularly  by  Tait,  Webster,  and 
Bland  Sutton. 

So  far  as  I  can  ascertain,  only  6  cases  of  so-called  ovarian  pregnancy 
have  been  reported  in  England  during  the  past  hundred  years — 2  by 
Granville  in  1834,  and  1  each  by  Oliver,  Croft,  Gilford,  and  Anning  and 


KXTUA   ITKUINE    PRK(i  X  A  N<  Y 


:,;;■ 


.  intervillous 
tiloodspaces 


Littlewood.    Of  the  instances  reported  in  this  country  up  to  L902,  Thomp- 
son's case  only  will  stand  a  rigid  scrutiny. 

The  earlier  unsatisfactory  condition  of  affairs  was  largely  due  to  the 
fact  that  proper  criteria  were  lacking,  and  as  a  consequence  many  speci* 
mens  were  described  as  ovarian  pregnancy  which  had  lit  lie  or  no  claim  to 
thai  title.  In  1878,  however,  Spiegelberg  formulated  certain  conditions 
«  Inch  must  be  I'ullilled  in  order  to  justify  such  a  diagnosis.  Se  demanded 
that  (1)  the  tube  on  the  affected  side  must  be  intact;  (2)  the  foetal  sac  must 
occupy  the  position  of  the  ovary;  (3)  it  must  be  connected  with  the  uterus 
by  the  ovarian  Ligament ;  and  n 

( t)    definite    ovarian    tissue  interna  and 

,     ,        j.  ,     .         ,,  Externa 

must  be  found  in  the  sac 
wall.  The  last  criterion 
should  be  still  further  modi- 
fied, and  it  must  be  shown 
that  ovarian  tissue  is  present 
in  several  portions  of  the  sac 
wall  at  some  distance  from 
one  another  before  the  evi- 
dence becomes  convincing. 
This  requirement  is  neces- 
sary, for  the  reason  that  in 
certain  cases  of  tubal  or 
broad-ligament  pregnancy 
the  ovary  may  become  flat- 
tened out,  and  to  a  certain 
extent  become  incorporated 
in  the  sac  wall. 

After  a  fairly  thorough 
search  through  the  litera- 
ture upon  ovarian  pregnancy 
for  the  past  hundred  years, 
I  have  collected  a  number 
of  cases,  which  I  have  classi- 
fied as  positive,  highly  prob- 
able, fairly  probable,  doubt- 
ful and  negative,  accord- 
ing  to   the    extent   to    which   they    fulfil    the    above-mentioned    criteria. 

In  only  5  cases  has  the  primary  ovarian  character  of  the  pregnancy  been 
conclusively  demonstrated — those  of  Gottschalk,  Kouwer  and  Tussen- 
broeck,  Anning  and  Littlewood,  Franz,  and  Thompson.  In  none  of  these 
was  there  any  doubt  concerning  the  anatomical  conditions.  Gottschalk's 
case  was  the  most  advanced,  the  ovary  being  converted  into  a  mass  the 
size  of  a  small  orange  in  which  was  a  distinct  foetus.  In  the  others  the 
product  of  conception  was  smaller.  Anning  and  Littlewood  exhibited  a 
specimen  before  the  London  Obstetrical  Society  in  1901,  which  was  so 
convincing  as  to  silence  the  objections  of  even  so  persistent  a  sceptic  as 
Bland  Sutton. 


Fig.  471. — Diagram  illustrating  Thompson's  Specimen 
of  Ovarian  Pregnancy  (Amer.  Gyn.). 


538 


OBSTETRICS 


Among  the  highly  probable  cases  I  have  included  13 — those  reported 
by  Granville,  Hein,  Uhde,  Franck,  Schrenck,  "Walther,  Spiegelberg,  Herz- 
feld,  Larsen,  Leopold,  Martin,  Gottschalk,  and  Ludwig.  The  first  5  had 
not  progressed  beyond  the  third  month,  while  the  others  had  reached  full 


Uterine  cavity. 


Partially  separated 
placenta. 


.ervix. 


Fig.  472. — Interstitial  Pregnancy  'Bumm). 

term.    In  the  cases  of  Leopold,  Gottschalk,  and  Martin  the  product  of  con- 
ception had  been  retained  in  the  abdomen  for  a  number  of  years. 

Among  the  fairly  probable  cases  I  have  included  those  of  Peuch,  Pa- 
tenko,  Geuer,  Kiistner,  Toth,  Croft,  and  Gilford,  making  a  total  of  25 
cases  in  which  a  positive  or  more  or  less  probable  diagnosis  is  justifiable. 

One  of  the  interesting  points  in  connection  with  the  cases  thus  far  re- 
corded is  that  10  of  the  25  reached  full  term.  This  would  go  to  show  that 
the  ovary  can  accommodate  itself  more  readily  than  the  tube  to  the  grow- 
ing pregnancy.  At  the  same  time,  it 
should  be  remembered  that  4  of  the  5 
positive  cases  ruptured  at  an  early 
period. 

Ovarian  pregnancy  results  from  the 
fertilization  of  the  ovum  before  it  es- 
capes from  the  Graafian  follicle,  the 
spermatozoa  entering  the  follicle  imme- 
diately after  its  rupture.  Leopold  be- 
lieves that  in  a  certain  number  of  cases 
a  deep-lying  follicle  may  rupture  into  a  more  superficial  one,  the  ovum  con- 
tained in  the  former  remaining  in  situ  and  being  fertilized  by  spermatozoa 
gaining  access  to  it  through  an  opening  in  the  more  superficial  follicle. 


Fig.  478. — Isthmic  Pregnancy.  Rupture 
Ten  Days  after  Last  Menstruax  Pe- 
riod.    X  1. 


KXTUA -UTKKINE    PREGNANCY 


539 


Tubal  Pregnancy. — In  this,  by  far  the  most  frequent  variety  of  extra- 
uterine pregnancy,  the  ovum  may  develop  in  any  one  of  the  three  portions 
of  the  lube,  giving  rise  to  an  interstitial,  isthmic,  or  amgyjjar  pregnancy  i 
respectively.    In  rare  instances'"^ may  b*e* implanted  upon  thennib r lat ebTj 
extremity,  and  occasionally  even  upon  the  fimbria  ovarica.     From  these! 
primary  types  certain  secondary  forms — tubo-abdominal,  tuho-ovarian,  and 
broad-ligament  pregnancy — occasionally  develop. 

According  to  Rosenthal,  the  interstitial  is  the  rarest  variety,  having 
occurred  in  only  3  per  cent  of  the  1,324  cases  of  tubal  pregnancy  which  he 
collected  from  the  literature.  Of  57  cases  analyzed  by  Martin  and  Orth- 
man,  48  were  ampullar,  8  isthmic,  and  only  1  was  interstitial.  More  recent 
writers,  as  Lindenthal,  state  that  the  isthmic  variety  is  the  commonest, 
and  this  has  also  been  my  experience. 


Fig.  474. — Kuptured  Ampullar  Pregnancy.     X  1. 
Am.,  amnion  ;  0.,  ovary ;  P.,  placenta  ;   T.,  uterine  end  of  tube. 

According  to  Tait,  rupture  occurring  not  later  than  the  .twelfth  week 
is  the  universal  termination  of  tubal  pregnancy.  More  careful  study,  how- 
ever, has  shown  that  only  one  fourth  of  the  cases  end  in  this  way,  the  other 
three  fourths  terminating  by  abortion  at  an  early  period.  Very  excep- 
tionally, the  pregnancy  may  go  on  to  full  term  without  rupture,  as  in  the 
cases  reported  by  Saxtorph,  Spiegelberg,  Chiari,  Gutzwiller,  Emanuel,  and 
others.    My  own  collection  also  contains  a  specimen  of  a  similar  case. 

Tubal  Abortion. — After  Werth,  in  1887,  had  directed  attention  to  the 
possibility  of  tubal  abortion,  it  has  gradually  been  demonstrated  that  this 
is  the  most  frequent  outcome  of  tubal  pregnancy.  The  marked  change  of 
opinion  upon  this  point  which  has  taken  place  being  clearly  indicated  by 
the  following  figures:  Thus,  whereas  in  1892  Schrenck  found  only  6  cases 
of  abortion  in  610  cases  of  tubal  pregnancy  collected  from  the  literature, 
the  recently  published  reports  of  Martin,  Wormser,  Mandl  and  Schmidt. 
Fehling  and  Glitsch,  comprising  289  cases,  show  that  78  per  cent  ended  by 
abortion  and  only  22  per  cent  by  rupture.  According  to  Martin,  "  this  ter- 
mination is  the  general  rule,  spontaneous  rupture  occurring  only  in  those 
cases  in  which  occlusion  of  the  abdominal  end  of  the  tube  precludes  the 
possibility  of  an  abortion,  or  in  which  the  ovum,  being  inserted  in  a  hernia 
of  mucosa,  burrows  directly  through  the  tube  wall." 


540  OBSTETRICS 

In  abortion,  the  connection  between  the  ovum  and  the  tube  wall  is  loos- 
ened, the  former  becoming  completely  or  partially  separated  from  its  site 
of  implantation  as  the  result  of  haemorrhage  due  to  the  sudden  opening  up 
of  maternal  vessels  by  the  growing  trophoblast  and  chorionic  villi.  If  the 
separation  is  complete,  the  effused  blood  gradually  forces  the  ovum  towards 
the  fimbriated  end  of  the  tube,  through  which  it  is  extruded  into  the  peri- 
toneal cavity,  whereupon  the  haemorrhage  usually  ceases.  On  the  other 
hand,  if  the  separation  is  only  partial,  the  ovum  remains  in  situ,  and  the 
haemorrhage  continues.  Accordingly,  we  distinguish  between  cojn^kte  and 
inco^wlete  abortions,  the  latter  occurring  far  more  frequently  than  the 
Tormer — 10  to  1,  according  to  Wormser. 


>L,$%/y.  \ 


Vs'\L 

\  / 
h.c.   \ 


I  ■    3—-i 

Fig.  475. — Eaely  Tubal  Pregnancy,  with  Abortion  of  Ovum  into  Lumen  of  Tube.     X  6. 
6.c,  blood-clot ;  v.,  chorionic  villi. 

In  a  small  number  of  cases  the  ovum  may  be  observed  in  the  act  of 
abortion  (Fig.  476).  Thus,  among  my  own  specimens  are  two  which  show 
the  foetus  surrounded  by  its  membranes,  protruding  from  the  dilated  fimbri- 
ated extremity  of  the  tube. 


EXTRA   CJTERENE    PREGNANCY  54] 

When  the  haemorrhage  is  moderate  In  amount  and  1 1 1  < -  ovum  remains 
in  situ,  it  may  become  infiltrated  with  blood  and   increase  markedly  in 


Fig.    176. — Tidal  Abortion,  Ovum  being   extruded  through   Fimbriated    Extremity  (Kelly). 

X  1. 

size,  being  converted  into  a  structure  analogous  to  the  blood  or  fleshy  mole 
observed  in  uterine  abortions  (Fig.  477).  The  haemorrhage  usually  persists 
as  long  as  the  mole  remains  in  the  tube,  and  the  blood  slowly  trickles  from 
the  fimbriated  extremity  into  the  peritoneal  cavity,  where  it  becomes  en- 
capsulated, giving  rise  to  an  hccmatocele.  If  the  fimbriated  extremity  is 
occluded,  the  tube  may  gradually  become  distended  hy  blood — Jicemato- 
salpinx. 

After  incomplete  abortion  small  particles  of  the  chorion  may  remain 
attached  to  the  tube  wall,  and,  becoming  surrounded  by  fibrin,  give  rise  to 
a  placental  polypus,  just  as  is  often  noted  after  an  incomplete  uterine 
abortion. 

Rupture  into  the  Peritoneal  Cavity. — About  one  fourth  of  the  cases  of 
tubal  pregnancy  end  within  the  first  twelve  weeks  by  rupture,  which  usually 
occurs  spontaneously,  but  occasionally  is  the  result  of  violence.  Generally 
speaking,  when  rupture  occurs  in  the  first  few  weeks,  the  pregnancy  is  situ- 
ated in  the  proximal  end  of  the  tube,  a  short  distance  from  the  cornu  of  the 
uterus  (see  Fig.  iToT  T5n  the  other  hand,  when  the  ovum  is  implanted  in 
the  interstitial  portion  of  the  tube,  rupture  occurs  later  than  in  the  other 
varieties — as  a  rule,  not  until  after  the  fourth  month,  sometimes  consider- 
ably later.  This  difference  is  due  to  the  fact  that  the  interstitial  portion  of 
the  tube  is  surrounded  by  uterine  musculature,  which  reacts  promptly  to 
the  stimulation  of  pregnancy,  and  by  its  hypertrophy  allows  the  ovum  to 
attain  a  considerable  size  before  rupture  occurs. 

The  underlying  causes  of  rupture  are  perforation  of  the  tube  wall 
by  the  growing  villi,  or  acute  overdistention  as  a  result  of  haemorrhage 
into  a  tube  whose  fimbriated  end  is  occluded.  The  mechanism  will  be 
more  clearly  understood  when  the  anatomical  relations  of  the  ovum  to  the 
tube  wall  are  studied.    Rupture,  as  a  rule,  occurs  in  the  neighbourhood  of 


542 


OBSTETRICS 


I—Or 


--B.C. 


-Section  through  Tubal  Mole. 
XI. 
B. C,  blood-clot;    Ov.,  ovum  ;    T.W.,  tube 
wall;  U.T.,  uterine  end  of  tube. 


the  placental  site,  and  may  take  place  either  into  the  rjej^1pii£al_cavLty  or 
between  the  folds  of  the  broad  ligament.     In  the  former  case  theenEire 

^SvmrT'rnay  be  extruded  or  remain  with- 
in the  tube.  In  either  event  the  acci- 
dent is  usually  accompanied  by  a  pro- 
fuse and  often  fatal  haemorrhage.  If 
the  2)atient  recovers,  the  effect  of  the 
rupture  upon  the  course  of  pregnancy 
varies  according  to  circumstances.  If 
the  ovum  be  expelled  entire  the  foetus 
must  inevitably  die,  and  the  product  of 
conception  will  be  rapidly  absorbed, 
unless  the  pregnancy  has  advanced  be- 
yond the  third  month.  This  fact  was 
proved  by  Leopold's  experimental  work 
upon  animals,  although  some  authors 
still  believe  that  under  such  circum- 
stances the  placenta  may  become  at- 
tached to  any  portion  of  the  perito- 
naeum and  there  establish  vascular 
connections,  thus  rendering  further 
development  of  the  ovum  possible. 
That  these  could  be  developed  soon  enough  and  before  the  ovum  be- 
came irreparably  damaged  seems  very  unlikely. 

If  the  foetus  only  escapes,  while  the  placenta  remains  within  the  tube, 
the  effect  will  vary  according  to  the  amount  of  injury  sustained  by  the 
placenta.  If  the  latter  be  much  damaged,  the  termination  of  pregnancy 
is  inevitable.  On  the  other  hand,  if  it  is  intact  and  remains  attached  to 
the  tube  wall,  further  development  is  possible,  and  gestation  may  go  on 
to  full  term  as  a  so-called  abdominal  pregnancy.  In  such  cases,  after  the 
escape  of  the  foetus,  the  tube  often  closes  clown  upon  the  placenta  and  forms 
a  sac  in  which  the  latter  remains  during  the  rest  of  pregnancy.  Less  fre- 
quently the  placenta  remains  attached  to  the  tube  wall,  but  as  it  increases 
in  size  its  peripheral  portions  extend  beyond  the  latter,  so  that  the  organ 
eventually  becomes  implanted  partly  upon  the  tube  and  partly  upon  the 
uterus,  pelvic  floor,  rectum,  or  even  the  intestines.  The  placenta  does  not 
become  attached  directly  to  organs  outside  of  the  pelvic  cavity — for  exam- 
ple, to  the  stomach  or  the  diaphragm.  When  such  a  condition  is  noted,  it  is 
probable  that  one  has  to  deal  with  a  broad-ligament  pregnancy,  in  which 
the  placenta  is  situated  in  the  upper  portion  of  the  gestation  sac,  and  that 
the  latter  has  become  adherent  to  the  organ  in  question. 

When  the  foetus  escapes  into  the  peritoneal  cavity,  according  to  the 
general  belief,  further  growth  is  impossible  unless  it  is  surrounded  by 
the  amnion.  Both  has,  however,  reported  an  exceptional  case  in  which  a 
fully  developed  foetus  lay  perfectly  free  in  the  abdominal  cavity,  all  that 
was  left  of  its  membranes  being  found  in  the  tubal  sac. 

Eupture  into  the  Broad  Ligament. — In  a  small  number  of  cases  rupture 
may  occur  at  the  portion  of  the  tube  uncovered  by  peritonaeum,  so  that  the 


EXTRA-UTERINE    PREGNANCY 


543 


contents  of  the  gestation  sac  arc  extruded  into  a  space  formed  by  the  sepa- 
ration of  the  folds  of  the  broad  Ligament.  Generally  speaking,  this  is  the 
most  favourable  variety  of  rupture,  and  may  terminate  either  by  the 
death  of  the  ovum  and  the  formation  of  a  broad-ligament  hematoma,  or  by 
the  further  development  of  the  pregnancy  between  the  folds  of  the  broad 
ligament.  The  outcome  depends  largely  upon  the  degree  of  completeness 
with  which  the  placenta  lias  been  separated  from  its  tubal  attachment. 

If  the  placenta  remains  attached  to  the  tube  on  the  side  opposite  the 
point  of  rupture,  it  generally  becomes  displaced  upward  as  pregnancy 
advances,  and  comes  to  lie  above  the  foetus;  but  when  it  is  situated  near  the 
point  of  rupture  it  gradually  extends  down  between  the  folds  of  the  broad 
ligament,  being  implanted  partly  upon  the  tube  and  partly  upon  the  pelvic 
connective  tissue.  In  either  event,  the  foetal  sac  lies  entirely  outside  of 
the  peritoneal  cavity,  and  as  it  increases  in  size  the  peritonaeum  is  gradually 


Fig.  478. — Broad-Ligament  Pregnancy  (Zweifel). 

dissected  up  from  the  pelvic  walls.  This  condition  is  designated  &s_e.rh-a: 
peritoneal  or  bro ad-Uga men t  ?)m7»6r»n/_^and  was  carefully  studied  by  Dezei- 
meris  in  1836.  Occasionally  the  broad-ligament  sac  may  rupture  at  a  later 
period,  and  the  child  be  extruded  into  the  peritoneal  cavity,  while  the  pla- 
centa retains  its  original  position — secondary  abdaminal_pregiwjici^ 

The  importance  of  rupture  into  the  broad  ligament  was  particularly 
emphasized  by  Tait,  who  believed  that  it  was  only  under  such  circumstances 
that  extra-uterine  pregnancy  could  go  on  to  full  term.  But  since  tubal 
pregnancy  does  not  necessarily  end  in  rupture,  it  is  evident  that  his  state- 
ments were  based  upon  imperfect  information.  The  frequency  of  this 
mode  of  rupture  seems  to  have  been  considerably  overestimated.  It  was 
noted  in  only  4  out  of  276  cases  collected  from  the  articles  of  Mandl  and 
Schmidt,  Kiistner,  and  Fehling,  and  only  once  in  50  specimens  of  extra- 
uterine pregnancy  examined  by  the  writer. 


544  OBSTETRICS 

The  so-called  tubo-uterine  vrea  nancy  results  from  the  gradual  extension 


into  the  uterine  cavity  of  an  ovuni  which  was  originally  implanted  in  the 
interstitial  portion  of  the  tube.  Tulo-abdominal  pregnancy,  on  the  other 
hand,  is  derived  from  a  tubal  pregnancy  in  which  the  ovum  has  been 
inserted  in  the  neighbourhood  of  the  fimbriated  extremity,  and  gradually 
extended  into  the  peritoneal  cavity.  Under  such  circumstances  the  por- 
tion of  the  foetal  sac  projecting  into  the  peritoneal  cavity  forms  adhesions 
with  the  surrounding  organs,  which  often  seriously  complicate  its  removal 
at  operation.  Xeither  of  these  conditions  are  very  common,  nor  do  they 
deserve  to  be  classified  separately;  in  reality,  they  are  merely  tubal  preg- 
nancies developed  at  unusual  portions  of  the  tubes. 

The  term  tubo-ovarian  pregnancy  is  employed  when  the  foetal  sac  is 
composed  partly  of  tubal  and  partly  of  ovarian  tissue.  Such  cases  owe 
their  origin  to  the  development  of  an  ovum  in  a  tubo-ovarian  cyst,  or  in 
a  tube  whose  fimbriated  extremity  was  adherent  to  the  ovary  at  the  time  of 
fertilization.  They  are  therefore  primarily  either  tubal  or  ovarian  in 
origin. 

Abdominal  Pregnancy. — Until  comparatively  recently  it  was  generally 
believed  that  the  ovum  could  be  implanted  upon  any  portion  of  the  peri- 
tonaeum and  give  rise  to  a  primary  abdominal  pregnancy.  Thus,  in  Hecker's 
statistics  abdominal  was  recorded  twice  as  frequently  as  tubal  pregnancy. 
Later,  however,  when  the  specimens  were  more  carefully  studied,  it  became 
apparent  that  the  great  majority  of  abdominal  pregnancies  were  secondary 
in  character,  having  resulted  from  ruptured  tubal  pregnancy. 

Gradually  doubt  began  to  be  cast  upon  the  existence  of  primary  ab- 
dominal pregnancy,  so  that  at  present  most  authors,  while  admitting  its 
theoretical  possibility,  are  extremely  sceptical  as  to  its  actual  occurrence. 
Occasionally,  as  was  shown  by  Zweif el,  Martin,  Yoigt,  and  Leopold,  the  fer- 
tilized ovum  may  become  implanted  upon  the  fimbria  ovarica.  Such  cases 
closely  resemble  primary  abdominal  pregnancy,  inasmuch  as  the  surface  to 
which  the  ovum  is  primarily  attached  is  so  small  that  as  pregnancy  advances 
the  margins  of  the  placenta  soon  extend  be}Tond  the  primary  seat  of  im- 
plantation and  become  attached  to  the  surrounding  organs,  thus  giving  the 
impression  that  it  was  primarily  implanted  upon  the  peritonaeum.  A  careful 
microscopical  examination,  however,  will  enable  one  to  differentiate  between 
the  two  conditions. 

Fate  of  Extra-uterine  Fcetus. — As  has  already  been  pointed  out,  absorp- 
tion^is  the  universal  fate  of  small  embryos  which  are  extruded  into  the 
peritoneal  cavity,  unless  the  placenta  retains  its  attachment  to  the  tube 
wall  and  still  offers  conditions  suitable  for  the  continuance  of  the  circula- 
tion. Moreover,  the  young  fcetus  is  frequently  absorbed  while  still  within 
the  tube,  as  is  shown  by  the  fact  that  upon  opening  early  gestation  sacs 
it  is  sometimes  represented  by  an  amphorous  mass  of  tissue  attached  to  the 
umbilical  cord.  At  times  the  only  indication  of  its  previous  existence  is 
found  in  a  small  portion  of  the  cord  hanging  free  in  the  amniotic  cavity. 
On  the  other  hand,  when  the  foetus  has  attained  a  certain  size  before  death 
it  cannot  be  absorbed  in  this  manner,  and  must  undergo  suju^uration,  mum; 
mification,  lithopgedion,  or  adipocere  formation. 


i:\TKA    ITKKINK    l'UKONAXCV  545 

Pyogenic  bacteria  often  gain  access  to  a  gestation  sac  which  is  ad- 
herent to  the  intestines,  and  give  rise  to  suppuration  of  its  contents. 
Eventually  the  abscess  perforates  ai  the  poinl  of  leasl  resistance,  and  if 
the  patiehl  does  not  die  from  septicaemia,  portions  of  the  foetus  may  be 
extruded  through  the  abdominal  wall  or  into  the  intestines  or  bladder,  ac- 
cording to  the  situation  of  the  perforation.  This  outcome  is  particularly 
frequent  in  broad-ligament  pregnancies,  on  account  of  their  proximity  to 
the  rectum  and  the  liability  to  infection  by  intestinal  bacteria. 

Mummification  and  lifhopcedion  formation  have  already  been  referred  to 
in  the  chapter  on  Abortion,  and  are  dealt  with  fully  in  Kiichennieister's  art  i- 
cle.  The  latter  is  generally  regarded  as  the  most  favourable  of  the  possible 
eventualities  in  cases  of  advanced  extra-uterine  pregnancy,  as  in  many 
instances  the  calcified  product  of  conception  may  be  carried  for  years  as 
a  harmless  foreign  body  and  do  no  harm,  unless  it  gives  rise  to  serious 
dystocia  in  a  subsequent  pregnancy.  In  several  instances  a  lithopsedion 
has  been  known  to  remain  in  the  abdomen  for  fifty  years  or  more,  and  the 
literature  contains  more  than  30  cases  in  which  a  period  of  twenty  to 
thirty  years  elapsed  before  its  removal  at  operation  or  autopsy. 

Much  more  rarely  the  foetus  may  become  converted  into  a  yellowish 
greasy  mass  to  which  the  term  adipocere  is  applied.  The  fatty  material 
is  supposed  to  be  an  ammoniacal  soap,  but  a  satisfactory  explanation  of 
its  formation  has  not  as  yet  been  advanced. 

Anatomical  Considerations. — Structure  of  the  Fatal  Sac. — In  extra- 
uterine pregnancy  there  is  a  marked  increase  in  the  vascularity  .of  the 
affected  tube,  the  larger  arteries  and  veins  being  much  hypertrophied,  while 
the  smaller  vessels,  especially  in  the  neighbourhood  of  the  placental  site,  are 
markedly  engorged. 

Microscopical  sections  through  the  sac  in  the  early  months  show  a 
slight  hypertrophy  of  the  muscle  cells,  but  no  apparent  increase  in  their 
number.  Except  at  the  placental  site,  the  tube  wall  is  considerably  thick- 
ened and  its  cells  are  spread  apart  by  oedema.  At  a  still  more  advanced 
period,  the  muscular  constituents  of  the  gestation  sac  appear  to  diminish 
in  number,  so  that  at  full  term  almost  its  entire  thickness  is  made  up  of 
a  connective  tissue  poor  in  cells,  with  only  here  and  there  a  muscle  fibre. 
This  indicates  that  the  muscularis  of  the  tube  does  not  possess  the  same 
tendency  to  hypertrophy  as  the  uterus,  though  occasionally  it  is  quite 
marked,  Pinard  having  reported  a  case  in  which  the  foetal  sac  contracted 
so  strongly  that  he  mistook  it  for  a  pregnant  uterus. 

In  most  cases  the  exterior  of  the  tube  gives  evidence  of  peritonitic  in- 
volvement, and  a  considerable  portion  of  the  thickness  of  the  foetal  sac 
is  often  due  to  peritoneal  adhesions. 


In  order  for  completetubal  abortion  to  occur,  the  fimbriated  extremity 
must  remain  patent,  but  in  other  cases  its  condition  varies,  being  sometimes 
closed,  sometimes  open.  As  a  rule  the  lumen  of  the  tube  communicates 
directly  with  either  end  of  the  foetal  sac.  Less  commonly,  however,  this 
communication  is  noted  only  at  one  end,  while  still  more  rarely  the  foetal 
sac  is  completely  shut  off  from  the  main  lumen.  A  satisfactory  explanation 
of  these  differences  has  not  as  yet  been  adduced. 


546 


OBSTETRICS 


Uterine  Decidua. — Under  the  influence  of  extra-uterine  gestation,  the 
endometrium  becomes  converted  into  a  decidua  similar  to  that  observed  in 
uterine  pregnancy,  and  differing  from  it  only  in  a  less  marked  development 

of  the  spongy  layer  and  a  greater 
abundance  of  blood  spaces  just  be- 
neath its  free  surface.  Soon  after  the 
death  of  the  foetus  the  decidua  is 
thrown  off  in  small  pieces,  and  occa- 
sionally as  a  triangular  cast  of  the  ute- 
rine cavity.  Its  discharge  is  usually 
considered  of  marked  diagnostic  sig- 
nificance: so  much  so  that  in  doubtful 
cases  many  observers  recommend  cu- 
retting the  uterus,  and  base  their  diag- 
nosis upon  the  presence  or  absence  of 
decidual  tissue. 

Decidua  Vera  and  Serotina. — All 
the  early  observers  stated  that  the  in- 
terior of  the  pregnant  tube  was  lined 
by  a  distinct  decidual  membrane  analo- 
gous to  the  decidua  vera  in  uterine 
pregnancy.  This  view  was  accepted 
without  question  until  1891,  when 
Bland  Sutton  denied  the  existence  of 
such  a  structure.  Later,  other  investi- 
gators, notably  Griffiths,  Kiihne,  Aschoff,  and  Kreisch,  stated  that  decidual 
cells  were  not  developed  in  the  pregnant  tube,  and  that  the  structures  which 
had  been  considered  as  such  were  foetal  in  origin  and  represented  the  pro- 
liferated trophoblast  or  foetal  ectoderm. 

While  there  is  no  doubt  that  a  great  part  of  the  so-called  decidual  cells 
are  really  foetal  in  origin,  I  am,  nevertheless,  confident  that  a  decidual  for- 
mation occurs,  though  to  a  far  less  marked  degree  than  was  believed  by  the 
early  observers.  At  the  same  time  it  must  be  admitted  that  the  authors 
just  mentioned  were  correct  in  denying  the  existence  of  a  continuous  mem- 
brane of  considerable  thickness,  analogous  to  the  decidua  vera  of  the  uterus, 
as  the  decidual  formation  is  limited  and  occurs^onhj  in  discrete  patches. 

That  the  tubes  are  capable  of  a  decidii^reae^n^has^been~concl^isively 
proved  by  the  observations  of  Mandl,  Lange,  and  others,  who  demonstrated 
its  occurrence  in  rare  cases  of  intra-uterine  pregnancy.  In  a  number  of 
specimens  of  tubal  pregnancy  which  I  have  examined,  there  was  a  distinct 
decidual  formation  not  only  at  the  site  of  implantation  of  the  ovum,  but 
also  in  folds  of  the  mucosa  some  distance  from  it — a  condition  also  noted 
by  Webster,  Voigt,  Both,  and  Dobbert.  In  one  case,  as  is  shown  in  Fig.  480, 
I  was  able  to  demonstrate  the  formation  of  decidual  cells  not  only  in  the 
pregnant,  but  also  in  the  non-pregnant  tube.  A  similar  observation  was 
also  made  by  Webster.  These  observations  would  appear  to  place  the  ques- 
tion beyond  all  doubt,  as  in  such  cases  there  could  be  no  possibility  of 
confusing  foetal  with  maternal  cells. 


Fig.  479. — Uterine  Decidua  from   a  Case 
of  Extra-Uterine  Pregnancy  (Zweifel). 


EXTRA-UTERINE   PREGNANCY 


>47 


What  lias  been  said  concerning  the  decidua  vera  in  tubal  pregnancy  ap- 
plies equally  well  to  the  decidual  serotina.  This  likewise  never  occurs  as 
a  continuous  membrane,  but  at  most  consists  of  a  few  patches  of  decidual 
cells,  which  can  be  distinguished  from  the  more  abundant  ftetal  cells 
only  by  the  most  careful  examination  (see  Fig.  481).  As  will  be  pointed 
out  later,  it  is  to  this  scanty  development  of  decidual  tissue  that  the  char- 
acteristic course  of  extra-uterine  pregnancy  is  to  be  attributed. 


ilii     ■""  ^ 


n 


Fig.  480. — Section  showing  Formation  of  Decidual  Cells  in  Eight  Tube,  -while  the  PREG- 
NANCY ^AS  IN  THE  OPPOSITE  TlTBE;  CONCLUSIVELY  DEMONSTRATING  THAT  THEV  COULD  NOT 
BE    OF    FcETAL    ORIGIN. 

m.m..  tubal  mucosa;  muse,  muscularis ;  d.,  deeidua. 

Decidua  Reflexa. — As  to  the  mode  of  implantation  of  the  ovum,  and 
whether  or  not  a  decidua  reflexa  is  developed  in  the  tube,  there  has  been 
not  a  little  discussion.  So  far  as  can  be  gathered  from  the  literature,  none 
of  the  more  recent  writers  describe  a  decidua  reflexa  analogous  to  that 
observed  in  uterine  pregnancy,  but  most  of  them  agree  that,  in  the  early 
stages,  at  least,  the  ovum  is  separated  from  the  main  lumen  of  the  tube 
by  a  thicker  or  thinner  layer  of  tissue,  which  practically  represents  the  de- 
cidua reflexa — the  r>seii']o-refexa Isee  Fig.  482).  This,  no  doubt,  contains 
isolated  decidual  cells  at  an  early  period,  but  its  inner  surface  soon  becomes 
invaded  by  f  cetal  ectoderm  and  undergoes  fibrinous  or  hyalin  changes.  Such 
36 


548 


OBSTETRICS 


a  structure  was  present  in  all  the  early  tubal  pregnancies  which  I  have 
examined,  and  the  recent  work  of  Couvelaire,  Heinsius,  Filth,  Petersen, 
and  others  confirms  my  experience. 


m'V  •*. 


38"* 


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^""'7":      "*  J '  Pf.    ,'    -'.''''     »*     *  ■   \  ■  "#*  ^:ejfc*^;%**!'*5?*4'*  ^'"f^      "■..-    •;-' 


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^joyt; 


Fig.  481. — Section  showing  Attachment  of  Chorion  to  Tube  Wall.     X  90. 
Dec,  decidual  cells  ;  L.C.,  Langbans's  cells  ;  Syn.,  syncytium  ;   V.,  villi. 

Mode  of  Attachment  of  the  Ovum. — The  ovum  becomes  attached  to  the 
tube  wall  just  as  it  does  to  the  endometrium — that  is,  it  penetrates  the 
surface  epithelium  and  burrows  down  into  the  tissue  beneath  it.  As  was 
said  before,  several  specimens,  which  I  had  previously  taken  as  indicating- 
the  development  of  the  ovum  in  a  diverticulum  from  the  lumen  of  the  tube, 
are  to  be  interpreted  in  this  manner  (see  Figs.  475  and  482). 

Owing  to  the  relative  paucity  of  decidual  cells,  the  changes  following 
the  implantation  of  the  ovum  differ  considerably  from  those  occurring  in 
normal  uterine  pregnancy.  As  there  is  no  distinct  decidual  membrane  to 
separate  the  growing  ovum  from  the  underlying  muscular  and  connective 
tissue,  the  rapidly  proliferating  trophoblast  comes  at  once  in  contact  with 
the  tube  wall,  and  promptly  leads  to  its  neomi^and  ultimate  conyer- 
.giominto  fibrin.  Since  this  tissue  opposes  but  slight  resistance  to  the  grow- 
L  ing  foetal  elements,  the  chorionic  villi  within  a  short  time  extend  through 
kthe  entire  thickness  of  the  tube  wall  and  come  to  lie  just  beneath  its  peri- 
toneal covering,  so  that  perforation  becomes  imminent.     For  the  same 


EXTRA  UTERINE  PREGNANCY 


549 


\ 


reason,  the  maternal  vessels  are  opened  up  much  more  rapidly  than  in 
uterine  pregnancy,  with  the  resuli  thai  in  many  cases  sudden  haemorrhage 
occurs  beneath  the  ovum,  thereby  separating  ii  from  its  attachments  and 
causing  an  abortion.  Again,  if  any  obstacle  is  opposed  to  1  he  escape  of  the 
blood  from  the  fimbriated  extremity,  the  thinned-oul  wall  yields  to  the 
sudden  increase  in  pressure  and  rupture  occurs. 

The  formation  of  the  placenta  is  .analogous  to  that  observed  in  uterine 
pregnancy,  the  only  difference  being  that  the  maternal  portion  is  made  up 
of  a  tissue  containing  very  Eew  decidual  cells,  instead  of  the  thick  mem- 
brane observed  in  the  uterus.  As  lias  already  been  pointed  out,  it  is  to  the 
absence__of  a  charactei-istdc  decidua  that  the  early  occurrence  of  abortion 
or  rupture  is  to  Be  attributed. 

Diseases  of  Extra-uterine  Ovum. — If  an  extra-uterine  pregnancy  goes  on 
without  interruption  beyond  the  first  few  months,  the  ovum  is  exposed  to 
all  the  diseases  which  may  occur  in  the  ordinary  uterine  form.    Thus,  hyda- 
tidiform  mole  has  been 
observed  by  Otto,  Reck- 
linghausen,   and   Wen- 
zel;    hydr  amnios    by 
Teuffel,    Webster,    and 
others;  and  deciduoma 
malignum    by    Ahlfeld 
and  Marchand. 

Symptoms.  —  Un- 
fortunately, the  mani- 
festations belonging  to 
an  uninterrupted  extra- 
uterine pregnancy  are 
not  characteristic,  and 
the  patient  and  her  phy- 
sician are  usually  en- 
tirely unaware  of  the 
existence  of  any  abnor- 
mality until  rupture  or 
tubal  abortion  occurs. 
Ordinarily  the  patient 
considers  herself  preg- 
nant, presents  the  usual 
subjective  symptoms, 
and  possibly  suffers 
from  slight  pains  in  one 
or  other  ovarian  region, 
which  she  regards  as  the 

usual  concomitants  of  her  condition.  In  rare  instances,  indeed,  she  ma}'- 
have  no  idea  that  she  is  pregnant,  and  rupture  may  occur  and  perhaps  prove 
fatal,  even  before  she  has  missed  a  single  menstrual  period. 

Suppression  of  the  menses  is  not  associated  so  regularly  with  this  con- 
dition as  with  normal  pregnancy,  being  noted  in  only  43  per  cent  of  the 


*>**v 


Fig.  482. — Early  Tubal  Pregnancy,  showing  Ovum  Embedded 

in  Wall  of  Tube  Outside  of  Lumen.     X  6. 

6.c,  blood-clot;  v..  chorionic  villi ;  reft.,  decidua  reflexa. 


550  OBSTETRICS 

cases  observed  by  Martin  and  Orth,  Mandl,  Bouilly,  and  Wormser.  These 
statements,  however,  do  not  carry  as  much  weight  as  would  appear  at  first 
sight,  for  frequently  the  hgemorrhage  does  not  represent  a  genuine  men- 
strual flow,  but  is  due  to  endometritis,  or  to  the  fact  that  the  dilated  vessels 
in  the  uterine  decidua  are  not  covered  by  a  layer  of  fcetal  tissue.  Moreover, 
the  death  of  the  extra-uterine  foetus  at  an  early  period,  if  not  accom- 
panied by  rupture  or  abortion,  is  usually  associated  with  more  or  less  uterine 
haemorrhage,  which  is  frequently  mistaken  for  the  menstrual  flow  or  for 
an  early  abortion,  the  latter  belief  being  still  further  confirmed  by  the  dis- 
charge of  decidua. 

In  many  cases  the  first  manifestation  of  the  abnormal  pregnancy  is  the 
sudden  occurrence  of  intense,  lancinating  pain  in  one  or  other  ovarian  re- 
gion, which  is  soon  followed  by  faintness,  the  patient  rapidly  passing  into  a 
condition  of  collapse.  This  indicates  the  occurrence  of  abortion  or  rup- 
ture. In  the  former  case  the  patient  usually  rallies  promptly,  whereas,  if 
rupture  has  occurred,  the  collapse  deepens,  the  face  becomes  -extremely 
pallid,  and  the  patient  complains  of  intense  pain  in  the  lower  abdomen. 
The  temperature  is  persistently  subnormal,  and  an  examination  of  the 
blood  shows  a  marked  diminution  in  the  number  of  red  corpuscles  and  in 
the  amount  of  haemoglobin.  Death  may  occur  within  a  few  hours  unless 
the  hgemorrhage  is  checked  by  operative  means.  On  the  other  hand,  in  most 
cases  of  abortion  the  general  condition  is  not  so  alarming,  and  the  patient 
gradually  recovers.  Vaginal  examination  a  few  days  later  frequently  reveals 
the  presence  of  a  large  fluctuant  mass  which  fills  a  greater  or  lesser  por- 
tion of  the  pelvic  cavity — pelvic  luematocele. 

In  the  earlier  text-books  on  gynaecology,  haematocele  was  considered  as 
a  distinct  disease,  and  it  was  mainly  owing  to  Veit's  observations  that  its 
connection  with  extra-uterine  pregnancy  was  established.  It  is  described  as 
diffuse  or  solitary,  according  as  the  collection  of  blood  occupies  a  con- 
siderable portion  of  the  pelvic  cavity  or  is  confined  to  the  neighbourhood 
of  the  fimbriated  end  of  the  tube.  The  diffuse  variety  usually  occurs 
when  pre-existing  adhesions  about  the  pelvic  organs  facilitate  the  coagula- 
tion of  blood  and  aid  in  the  formation  of  an  organized  membrane  over  it, 
thus  shutting  it  off  from  the  peritoneal  cavity.  According  to  Sanger,  the 
solitary  haematocele,  on  the  other  hand,  does  not  require  the  presence  of 
adhesions  for  its  formation,  but  results  from  the  gradual  trickling  of 
blood  from  the  fimbriated  end  of  the  tube,  the  outer  portions  gradually 
coagulating  and  becoming  organized,  thus  forming  a  capsule  about  the 
more  fluid  portions. 

Hematocele  formation,  for  the  most  part,  promises  a  very  favourable 
termination,  for  if  left  alone  the  mass  gradually  undergoes  absorption  and 
complete  recovery  occurs.  Thorn  has  reported  157  cases  with  two  fatalities, 
and  Fehling  91  cases  without  a  single  death.  Occasionally,  however,  if 
the  haemorrhage  persists,  the  hematocele  becomes  larger  and  larger  until 
it  finally  ruptures  and  its  contents  are  poured  out  into  the  peritoneal 
cavity.  Such  an  accident  is  speedily  followed  by  collapse.  Again,  bacteria 
sometimes  make  their  way  into  the  mass  from  the  intestines  and  cause 
suppuration. 


EXTRA    I'TKUINK    I'KMJXANCY  551 

[f  the  patient  survives  the  rupture  of  a  tubal  pregnancy,  a  secQjyfary 
abdominal  grgflaflfflcyjnay  result,  provided  the  placenta  has  qoI  beer  sepa- 
rated to  too  greal  an  extent.  Under  such  circumstances  the  usual  symptoms 
of  pregnancy  persist,  except  that  the  woman  suffers  more  pain  and  feels  the 

fogta l_mo ve mei its  more  acutely  than  usual.  The  pain  is  due  partly  to 
sketching  and  possibly  to  contractions  of  the  foetal  sac,  but  principally  to 
the  pulling  apart  of  adhesions  which  have  formed  between  the  sac  and  the 
various  abdominal  organs. 

In  a  small  number  of  cases  of  broad-ligament  pregnancy,  secondary 
rupture  into  the  peritoneal  cavity  may  occur  at  a  later  period,  and  the 
patient  may  bleed  to  death,  or  else  a  secondary  abdominal  pregnancy  may 
result.  In  such  cases  the  foetus  lies  within  the  peritoneal  cavity,  while  the 
placenta  remains  partly  within  the  tube  and  partly  between  the  folds  of 
the  broad  ligament. 

If  a  secondary  abdominal  pregnancy  or,  as  now  and  again  occurs,  an 
unruptured  tubal  pregnancy  goes  on  to  term,  fajj^Jabowr  sets  in,  associated 
with  distinct  pains  similar  to  those  occurring  in  theearry  stages  of  labour 
in  normal  pregnancy.  They  are  due  to  uterine  contractions,  since  the  fcetal 
sac  contains  so  few  muscular  fibres  that  it  cannot  contract,  and  of  course 
cannot  lead  to  the  birth  of  the  extra-uterine  child.  False  labour  may  last 
for  a  few  hours  or  several  days,  and  is  soon  followed  by  the  death  of  the 
child,  although  in  a  small  number  of  cases  the  fcetal  movements  have  been 
known  to  persist  for  a  considerable  time  after  the  cessation  of  the  pains. 

After  the  death  of  the  foetus,  the  pla^ental^jjrculation  gradually  ae=_ 
comes  abolished,  the  anrni ot i c^fhj^d  is  absorbed,  and  the  fcetal  sac  retracts, 
so  that  it  occupies  a  much  smaller  space  than  formerly.  The  abdomen 
consequently  becomes  smaller,  and  its  change  in  size  is  soon  noticed  by  the 
patient.  After  its  initial  shrinking,  the  tumour  may  remain  stationary  in 
size  for  a  number  of  years,  the  child  becoming  mummified  or  converted 
into  a  lithopsedion;  while  in  rare  instances  suppurative  changes  may  lead  to 
its  gradual  discharge  or  to  the  death  of  the  patient  from  peritonitis. 

Combined  and  Multiple  Pregnancies. — Parry  stated  in  his  monograph 
that  22  out  of  the  500  cases  of  tubal  pregnancy  collected  by  him  were  com- 
plicated by  a  coexisting  intra-uterine  pregnancy.  He  designated  the  condi- 
tion as  combined  pregnancy.  The  subject  has  since  been  investigated  by 
Browne,  Pantellani,  flutzwiller,  Strauss,  Zincke,  and  others,  Strauss  having 
collected  32  cases  which  had  been  reported  up  to  1898,  not  including  a  num- 
ber of  Parry's  cases.    Zincke,  in  1902,  collected  88  cases. 

In  rare  instances  twin  tubal  pregnancy  has  been  observed,  the  embryos 
being  sometimes  found  in  the  same  tube,  while  in  other  cases  there  was  a 
foetus  in  each  tube,  both  showing  the  same  development.  Sanger  and 
Krusen  have  reported  cases  of  triplet  tubal  pregnancy. 

Bepeated  Tubal  Pregnancy. — Parry  collected  8  cases  in  which  tubal  preg- 
nancy had  occurred  a  second  time  in  the  same  patient,  and  stated  that  Prim- 
rose, in  1594,  was  the  first  to  describe  such  a  condition.  With  the  increased 
employment  of  abdominal  surgery,  the  abnormality  has  been  recognised 
quite  frequently,  the  first  series  of  cases  w&s  reported  by  Abel  in  1893,  and 
soon  followed  by  those  of  Dorland,  Weil,  Yarnier,  and  Pestalozza,  the  last 


552  OBSTETRICS 

author  having  collected  111  cases.  In  several  instances  only  a  few  months 
had  elapsed  between  the  two  pregnancies,  while  in  others  they  were  sepa- 
rated by  an  interval  of  several  years. 

Effects  of  Extra-uterine  Pregnancy  upon  Subsequent  Childbearing. — 
The  presence  of  the  products  of  an  old  extra-uterine  pregnancy  occasion- 
ally gives  rise  to  dystocia  and  necessitates  the  performance  of  a  major 
obstetrical  operatioTn  Thus,  in  the  cases  reported  by  Hugenberger, 
Schauta,  and  Sanger,  Csesarean  section  was  performed;  while  in  another, 
reported  by  Ott,  the  same  operation  would  have  been  necessary  had  miscar- 
riage not  occurred  at  the  sixth  month.  Hennigsen,  Dibot,  and  Brossi  in- 
duced premature  labour,  and  Stein  and  Cheston  resorted  to  craniotomy 
under  similar  circumstances. 

As  a  rule,  however,  dystocia  is  not  encountered,  Funck-Brentano  hav- 
ing collected  92  cases  in  which  spontaneous  labour  occurred  in  patients  still 
carrying  the  remains  of  a  previous  extra-uterine  pregnancy. 

Diagnosis. — Unfortunately,  the  symptoms  to  which  uninterrupted 
extra-uterine  pregnancy  gives  rise  are  usually  so  slight  that  the  woman 
does  not  consult  a  physician,  and  as  a  result  the  diagnosis  is  rarely  made 
before  rupture  or  abortion  occurs.  If,  however,  a  patient  presenting  the 
usual  subj£ctive_  and  some  of  the  objective  symptoms  of  pregnancy  be 
examinecTTor  any  reason,  and  a  uirjkiteral  tribal  ^tumguji  be  found,  the 
diagnosis  is  fairly  certain,  especially  if  she  has  been  sterile  for  a  number 
of  years  or  a  long  interval  has  elapsed  since  her  last  pregnancy.  In  such 
cases  the  uterus  is  somewhat  enlarged  and  softened,  while  the  tubal  tu- 
mour is  softiincTdoughy,  and  corresponds  roughly  irTsize  to  the  supposed 
duration  of  pregnancyT"  The  first  positive  diagnosis  of  unruptured  tubal 
pregnancy  was  made  by  Veit  in  1883,  and  in  this  country  by  Janvrin 
in  1886. 

As  a  matter  of  fact,  however,  it  very  often  happens  that  when  laparot- 
omy is  performed  for  a  supposed  unruptured  tubal  pregnancy  a  tumour  of 
some  other  origin  is  found.  On  the  other  hand,  the  unruptured  pregnant 
tube  may  prolapse  into  Douglas's  cul-de-sac  and  be  mistaken  for  the  body 
of  a  retroflexed  pregnant  uterus,  so  that  an  attempt  at  its  reposition  not 
infrequently  leads  to  rupture  and  occasionally  to  death. 

When  the  foetus  has  died  before  the  occurrence  of  rupture  or  abortion, 
errors  in  diagnosis  are  common,  and  many  cases  are  mistaken  for  incom- 
plete uterine  abortions  or  for  tubal  tumours  associated  with  uterine  haemor- 
rhage. For  this  reason  no  attempt  should  ever  be  made  to  empty  the 
uterus  in  a  case  of  suspected  incomplete  abortion  unless  the  tubes  and 
ovaries  have  been  previously  palpated.  If  a  careful  examination  shows  that 
a  tumour  is  present  on  either  side,  the  possibility  of  tubal  pregnancy  should 
be  seriously  considered. 

It  is  generally  taught  that  the  discharge  of  a  distinct  decidual  cast  from 
the  uterus,  without  evidence  of  a  foetus,  is  a  characteristic  sign  of  tubal 
pregnancy.  But  that  now  and  again  such  a  structure  may  be  discharged 
without  the  existence  of  pregnancy  of  any  kind  was  demonstrated  by  Grif- 
fiths and  Dakin.  Ott  and  Ayers  believe  that  the  presence  of  decidual  tissue 
in  the  uterus,  in  the  absence  of  a  foetus,  affords  conclusiveevidence  aFTrie" 


EXTRA  UTERINE  PREGNANCY  553 

existence  of  tubal  pregnancy,  especially  if  a  1  umour  mass  can  be  detected  on 
one  side.  In  doubtful  cases  they  recommend  curettage  Eor  diagnostic  pur- 
poses. Mv  own  experience  has  taught  me  that  the  presence  of  decidua 
under  such  circumstances  usually  affords  sinrng^juvsuiiipiive  evidence,  bul 
thai  its  absence  is  uol  an  equally  convincing  aegative  proof,  for  occasion- 
ally tin1  decidua  may  have  been  casl  nil'  ;;t  an  early  period  and  been  replaced 
by  normal  endometrium  by  the  time  the  patient  is  examined. 

The  diagnosis  of  tubal  abortion  or  rupture,  on  the  other  hand,  usually 
offers  n<»  difficulty,  and  should  he  made  without  hesitation  whenever  a 
patient  who  is  believed  to  be  pregnant  has  complained  of  pain  in  the  lower 
part  of  the  abdomen,  and  suddenly  becomes  faint,  deathly  pale,  and  sinks 
into  a  state  of  collapse.  If  the  collapse  becomes  more  profound  and  the 
temperature  is  subnormal,  rupture  has  probably  occurred.  On  the  other 
hand,  if  rapid  recovery  ensues,  the  probabilities  are  that  one  has  to  deal 
with  an  abortion,  and  the  subsequent  formation  of  an  hematocele  settles 
the  question. 

As  has  already  been  pointed  out,  rupture  may  occur  at  a  very  early 
period,  even  before  the  patient  believes  herself  pregnant.  In  view  of  such 
a  possibility,  therefore,  one  should  regard  sudden  collapse  associated  with 
symptoms  of  abdominal  haemorrhage  in  a  woman  during  the  childbearing 
period,  as  prima  facie  evidence  of  a  ruptured  tubal  pregnancy.  By  so  doing, 
and  operating  promptly  in  suitable  cases,  a  number  of  lives  will  be  saved 
"which  otherwise  would  inevitably  be  lost. 

Very  often  the  patient  comes  into  the  hands  of  the  physician  some  time 
after  she  has  recovered  from  the  primary  shock  due  to  abortion  or  rup- 
ture. Under  such  circumstances  vaginal  examination  will  show  a  mass  on 
one  side  of  the  uterus  which  is  usually  mistaken  for  pelvic  inflammatory 
trouble.  In  a  small  number  of  cases,  a  fluctuant  tumour  can  be  felt  pos- 
terior and  lateral  to  the  uterus,  and  when  exploratory  puncture  through  the 
vagina  reveals  the  presence  of  a  dark  bloody  fluid,  the  diagnosis  of  a 
pelvic  hematocele  or  a  broad-ligament  hasmatoma  is  assured. 

The  diagnosis  of  secondary  abdominal  pregnancy  is  rarely  made  until 
false  labour  supervenes,  unless  the  physician's  attention  is  particularly 
directed  to  the  previous  history  of  the  case.  If,  however,  a  careful  physical 
examination  is  made,  the  uterus  will  be  found  much  smaller  than  it  should 
be  for  the  duration  of  the  pregnancy,  and  more  or  less  displaced  by  the 
foetal  sac.  which  makes  up  the  greater  part  of  the  abdominal  enlargement. 
Moreover,  the  child  can  be  palpated  much  more  readily  than  usual,  and  its 
movements  are  often  very  painful  to  the  mother.  In  doubtful  cases  the 
introduction  of  a  sound  into  the  uterus  is  permissible. 

The  diagnosis  of  broad-ligament  pregnancy  can  be  made  by  finding  the 
uterus  pushed  to  one  side  by  a  tumour  intimately  connected  with  it.  which 
at  the  same  time  depresses  the  vaginal  vault  instead  of  being  high  up  in 
the  abdominal  cavity. 

The  diagnosis  of  combined  intra-uterine  and  extra-uterine  pregnancy  is 
rarely  made  until  rupture  of  the  extra-uterine  pregnancy,  or  the  persistence 
of  symptoms  after  the  expulsion  of  the  uterine  foetus,  leads  to  a  very  careful 
-examination.    The  condition  has  never  been  diagnosed  in  the  later  months 


554  OBSTETRICS 

of  pregnancy,  although  in  several  instances  the  presence  of  twins  was  rec- 
ognised. 

After  extra-uterine  pregnancy  has  reached  full  term  the  diagnosis  is 
usually  easy,  and  is  based  upon  the  history  of  pregnancy  followed  by  a 
false  labour  and  a  gradual  decrease  in  the  size  of  the  abdomen.  Examina- 
tion shows  the  uterus  to  be  practically  normal  in  size,  and  displaced  to  a 
varying  extent  by  a  large  tumour  more  or  less  intimately  connected  with 
it,  in  which  the  outlines  of  the  child  can  occasionally  be  distinguished. 

To  recapitulate,  a  positive  diagnosis  is  occasionally  made  before  rup- 
ture, but  in  the  vast  majority  of  cases  the  condition  escapes  recognition 
until  symptoms  of  collapse  point  to  the  probability  of  rupture  or  abortion. 
In  advanced  cases  careful  examination  will  usually  disclose  the  real  condi- 
tion of  affairs,  and  when  full  term  has  been  passed  the  history  is  so  charac- 
teristic that  mistakes  should  hardly  occur. 

Treatment. — As  soon  as  an  unruptured  extra-uterine  pregnancy  is  posi- 
tively diagnosed,  its  immediate  removal  by  laparotomy  is  urgently  indi- 
cated, since  rupture  may  occur  at  any  time  and  the  patient  die  from  hsemor- 
rhage  before  operative  aid  can  be  obtained.  The  importance  of  immediate 
operation  cannot  be  too  strongly  emphasized,  and  all  methods  of  treatment 
which  aim  at  destroying  the  foetus  and  thus  terminating  pregnancy  with- 
out operation  are  absolutely  unjustifiable.  This  applies  not  only  to  the 
use  of  electricity,  but  also  to  the  injection  of  various  poisonous  substances 
into  the  gestation  sac.  Even  when  such  procedures  are  successful,  the 
danger  to  the  mother  is  by  no  means  at  an  end,  since  rupture  sometimes 
takes  place  after  the  death  of  the  foetus;  and,  even  if  this  accident  does  not 
occur,  the  retention  of  the  product  of  conception  renders  the  tube  a  useless 
organ. 

Tait,  in  1883,  performed  the  first  laparotomy  for  the  purpose  of  check- 
ing haemorrhage  from  a  ruptured  tubal  pregnancy.  After  he  had  demon- 
strated the  ease  with  which  the  procedure  could  be  performed  and  the 
surprisingly  good  results  obtained  thereby,  the  operation  came  into  general 
use.  Its  beneficent  results  were  clearly  demonstrated  by  Schauta,  who,  after 
a  careful  study  of  the  literature,  found  that  123  cases  operated  upon  and  121 
cases  treated  without  operation  presented  a  mortality  of  5.7  and  86.9  per 
cent  respectively. 

For  these  reasons,  whenever  we  see  a  possibly  pregnant  woman  in  a 
state  of  profound  collapse,  and  presenting  a  deathly  pallor  of  the  face,  a 
subnormal  temperature,  and  other  symptoms  of  intra-abdominal  haemor- 
rhage, immediate  operation  is  demanded,  unless,  indeed,  her  condition  is 
so  desperate  that  death  is  imminent. 

The  abdomen  should  be  opened  rapidly,  under  cocaine  anaesthesia  if 
necessary.  In  many  cases  blood  spurts  from  the  abdomen  as  soon  as  the 
peritonaeum  is  incised,  and  completely  obscures  the  field  of  operation. 
Under  these  circumstances  the  hand  passed  down  alongside  of  the  uterus 
seizes  the  tubal  mass,  which  is  then  clamped  on  either  side  by  long  for- 
ceps. The  haemorrhage  having  been  controlled  in  this  way,  the  blood- 
clots  are  removed  and  the  field  of  operation  is  cleaned  up,  after  which  the 
operator  will  be  able  to  remove  the  mass  and  replace  the  clamps  by  liga- 


EXTRA-UTERINE   PREGNANCY  555 

lures,  under  bhe  guidance  of  the  eye,  at  comparative  leisure.  After  the 
foetal  sac  has  been  taken  away,  it  is  not  advisable  to  atteiupl  t<>  remove  all 
the  blood  from  the  peritoneal  cavity  unless  the  patient's  condition  is  fairly 
sal  is  factory. 

Not  infrequently  the  appendages  on  the  opposite  side  may  be  the  seat 
of  chronic  inflammatory  lesions.  Some  discretion  should  be  exercised  as  to 
their  removal  at  this  time,  it  being  far  better  to  allow  them  to  remain 
than  to  prolong  the  operation  if  the  patient  is  in  a  very  bad  condition.  In 
desperate  cases  it  is  advisable  to  begin  the  subcutaneous  or  intravenous 
infusion  of  sterile  salt  solution  while  the  necessary  preparations  for  the 
operation  are  being  made.  In  less  severe  cases  good  results  follow  the  intro- 
duction of  several  litres  of  it  into  the  abdomen  just  before  the  wound  is 
closed. 

In  certain  cases  of  tubal  abortion,  Prochownick,  Martin,  and  others  ad- 
vocate attempting  to  save  the  tube,  if  possible,  by  opening  it  and  remov- 
ing the  product  of  conception,  after  which  it  is  closed  by  sutures.  Such 
a  procedure  may  occasionally  be  advisable  if  the  patient  is  in  good  condi- 
tion, but  proof  is  still  lacking  that  a  tube  so  treated  regains  its  normal  func- 
tions. 

A  freshly  ruptured  tubal  pregnancy  should  not  be  attacked  through 
the  vagina,  for  the  reason  that  the  procedure  is  often  more  difficult  than 
a  laparotomy,  and  affords  but  a  limited  view  of  the  field  of  operation,  while 
there  is  always  a  possibility  that  it  cannot  be  completed  by  the  vaginal 
route,  and  that  an  eventual  resort  to  laparotomy  will  become  necessary. 

If  the  patient  is  not  seen  until  the  acute  symptoms  have  subsided  and 
the  effused  blood  has  become  encapsulated  as  an  hasmatocele,  she  should 
be  put  to  bed  and  carefully  watched,  operative  procedures  being  insti- 
tuted only  when  the  hematocele  steadily  increases  in  size  or  presents  symp- 
toms indicative  of  suppuration.  This  condition,  however,  rarely  presents 
itself,  and  Thorn  operated  upon  only  6  out  of  157  such  cases.  When,  how- 
ever, the  occasion  demands  it,  excellent  results  are  obtained  by  evacuating 
the  hematocele  through  an  incision  in  the  vaginal  fornix  and  packing  the"1 
cavity^witrTs'terile  gauze,  as  has  been  recommended  by  Kelly,  Segond,  and 
others.    Broad-ligament  hematomata  should  be  treated  in  a  similar  manner. 

In  the  later  months,  the  treatment  of  extra-uterine  pregnancy  differs 
markedly  according  as  the  foetus  is  alive  or  dead.  In  very  rare  cases  a  living 
foetus  may  be  inclosed  in  an  unruptured  tubal  or  ovarian  sac,  or  lie  be- 
tween the  layers  of  the  unfolded  broad  ligament.  More  frequently,  how- 
ever, one  has  to  deal  with  a  secondary  abdominal  pregnancy,  with  the 
child  lying  in  the  peritoneal  cavity  and  inclosed  in  a  sac  composed  of 
the  foetal  membranes  and  newly  formed  adhesions,  the  placenta  being 
within  the  tube  or  broadly  implanted  upon  the  floor  of  the  pelvis.  What- 
ever the  anatomical  conditions,  the  mother  is  constantly  exposed  to  the 
possibility  of  sudden  and  acute  haemorrhage  so  long  as  pregnancy  continues, 
and  accordingly  prompt  laparotomy  is  the  only  conservative  method  of 
treatment. 

When  the  child  has  nearly  attained  the  period  of  viability,  certain  au- 
thorities urge  the  propriety  of  deferring  the  operation  for  a  few  weeks  in 


556  OBSTETRICS 

its  interests.  Such  a  course  may  be  permissible  in  exceptional  cases,  pro- 
vided the  increased  dangers  of  waiting  are  carefully  explained  to  the  patient 
and  her  family  and  accepted  by  them. 

In  a  small  number  of  cases  the  operation  is  comparatively  easy  and  the 
foetal  sac  can  be  removed  as  readily  as  a  large  ovarian  cyst.  More  frequently, 
however,  the  foetal  sac  is  markedly  adherent  to  surrounding  organs,  or  the 
placental  attachment  is  spread  over  a  broad  area,  thereby  markedly  in- 
creasing the  difficulty  of  the  operation. 

Now  and  again,  in  broad-ligament  pregnancies  it  will  be  found  that 
the  portion  of  the  broad  ligament  immediately  adjoining  the  uterus  has 
not  been  spread  apart  by  the  growing  ovum,  and  under  such  circumstances 
the  entire  sac  may  be  removed  without  great  difficulty  by  ligating  the  ves- 
sels at  the  pelvic  brim  and  at  the  uterine  cornu  before  attempting  its 
enucleation. 

As  a  rule,  however,  the  complete  removal  of  the  gestation  sac  is  by  no 
means  easy,  and  can  only  be  effected  by  removing  the  uterus  as  well."  When, 
as  occasionally  happens,  it  is  apparent  that  the  operation  cannot  be  com- 
pleted without  markedly  endangering  the  life  of  the  patient,  the  sac  should 
be  incised,  the  placenta  being  avoided,  if  possible,  and  the  foetus  extracted. 
The  margins  of  the  sac  are  then  stitched  to  the  abdominal  incision,  the  um- 
bilical cord  is  cut  off  short,  and  the  cavity  packed  with  sterile  gauze,  the 
placenta  being  left  in  situ  and  afterward  allowed  to  come  away  piece- 
meal. This  method  necessarily  entails  a  prolonged  convalescence,  but  is 
much  safer  than  any  attempt  at  removal  of  the  placenta.  Occasionally, 
however,  partial  separation  of  the  placenta  gives  rise  to  such  profuse  haemor- 
rhage that  its  removal  must  be  effected  at  any  cost  in  the  hope  of  prevent- 
ing immediate  death. 

The  results  following  laparotomy  in  advanced  cases  of  extra-uterine 
pregnancy  with  a  living  child  have  improved  markedly  since  the  introduc- 
tion of  aseptic  methods.  This  fact  was  clearly  shown  by  Harris,  who  col- 
lected 27  such  cases  in  1887  and  145  additional  cases  ten  years  later,  with 
a  mortality  of  93  and  31  per  cent  respectively.  iSTevertheless,  the  operation 
is  still  one  of  the  most  dangerous  which  the  gynaecologist  is  called  upon  to 
perform. 

When  the  foetus  is  dead  the  conditions  are  much  more  favourable,  as  the 
dangers  incident  to  bleeding  from  the  placental  site  are  markedly  dimin- 
ished. For  this  reason  the  operation  should  be  deferred  for  six  or  eight 
weeks  after  foetal  death  in  order  to  permit  the  obliteration  of  the  maternal 
blood  spaces  in  the  placenta,  and  thus  render  possible  its  removal  without 
haemorrhage.  In  such  cases,  however,  should  dangerous  symptoms  super- 
vene, immediate  interference  is  indicated.  On  the  other  hand,  the  operation 
should  not  be  deferred  too  long,  as  there  is  always  a  possibility  that  the 
foetal  sac  may  become  infected  from  the  intestinal  tract,  when  a  fatal  peri- 
tonitis may  result.  Lusk,  in  1886,  made  an  earnest  plea  for  prompt  opera- 
tion in  such  cases,  and  supported  his  contention  by  a  long  array  of  sta- 
tistics. 

In  a  small  number  of  cases  of  advanced  extra-uterine  pregnancy,  opera- 
tion through  the  vagina  has  been  recommended.     This  method  of  proce- 


EXTRA-UTERINE   PREGNANCY  557 

dure,  however,  has  a  very  limited  field,  and  Herman  is  right  in  saying  that 
ii  should  1h>  performed  only  when  the  foetus  is  firmly  impacted  in  the  pelvis 
and  depresses  the  vaginal  vault  to  such  an  extent  as  to  make  it  probable 
that  it  can  be  extracted  without  diiliculty.  In  all  other  cases  laparotomy 
is  the  operation  of  choice. 

LITERATURE 

Abel.    Zur  Anatomic  der  Eileitersehwangerschaft  nebst  Bemerkungen  zur  Entwickelung 
der  menschlichen  Placenta.     Arcliiv  f.  Gyn..  1891,  xxxix,  393-436. 
Ueber  wiederholte  Tubengraviditat   bei  derselben  Frau.    Archiv  f.  Gyn..  1893,  xlv, 
55-89. 

Ahlfeld.  Ein  Fall  von  Sarcoma  uteri  deciduo-cellulare  bei  Tubenschwangerschaft. 
Monatsschr.  f.  Geb.  u.  Gyn.,  1895,  i,  209-213. 

Axxixu  and  Littlewood.  A  Case  of  Primary  Ovarian  Pregnancy,  etc.  Trans.  London 
Obst.  Soc.  1901,  xliii :  Lancet,  1901,  i,  100. 

Aschoff.     Anatomie  der  Extrauteriuschwangerschaft.     Ziegler's  Beitrage,  1899,  xxv,  H.  2. 
Die  Beziehungen  der  tubaren  Placenta  zum  Tubenabort  und  zur  Tubenruptur.    Archiv 

f.  Gyn.,  1900,  lx,  523-533. 
Neuere  Arbeiten  iiber  die  Anat.  u.  Aetiologie  der  Tubenschwangerschaften.    Centralbl. 
f.  allg.  Path.  u.  path.  Anat.,  1901,  Nr.  11  u.  12. 

Ayers.  Decidua  in  the  Diagnosis  of  Extra-uterine  Pregnancy.  Amer.  Jour.  Obst.,  1892, 
xxvi,  289-306. 

Beck.  Ectopic  Pregnancy  Twice  in  the  Same  Patient,  the  Second  Time  complicated  by 
Intestinal  Obstruction.     Amer.  Jour.  Obst.,  1893,  xxvii,  570-576. 

vox  Both.  Rechtsseitige  Tubarschwangerschaft.  Ruptur  im  5ten  Monat.  Entbindung 
des  frei  in  der  Bauchhohle  lebenden  Kindes  durch  Laparotomie  im  8ten  Monat.  Mo- 
natsschr. f.  Geb.  u.  Gyn.,  1899,  782-79-1. 

Bolilly.  Xotes  sur  la  grossesse  extra-uterine  tirees  de  l'analyse  de  cinquante  observa- 
tions personelles.     La  Gynecologic,  1898,  iii,  1-16. 

Breslau.  Zur  Aetiologie  und  path.  Anatomie  der  Extrauterinschwangersehaft,  Mo- 
natsschr. f.  Geb.  u.  Gyn.,  1863,  xxi,  Supplement  Heft,  119-124. 

Brossi.     Quoted  by  Sanger. 

Browxe.  A  Contribution  to  the  History  of  Combined  Intra-uterine  and  Extra-uterine 
Twin  Pregnancy.     Trans.  Amer.  Gyn.  Soc,  1882,  vi,  444-462, 

Campbell.  Abhandlung  iiber  die  Schwangerschaft  ausserhalb  der  Gebarmutter.  Trans- 
lated from  the  English  by  Dr.  Ecker.  Karlsruhe  and  Freiburg.  1841. 

Chestox.     Quoted  by  Funck-Brentano. 

Chiari.     Beitrage  zur  Lehre  von  der  Graviditas  tubaria.     Zeitschr.  f.  Heilkunde,  1887.  viii. 

Couvelaire.     Note  sur  l'anatomie  de  la  reflechie  dans  la  grossesse  tubaire.     Comptes 
rendus  Soc.  d'obst.  de  gyn.  et  de  pa?d.  de  Paris.  1900,  ii.  50-61. 
Quelques  points  de  l'anatomie  des  grossesses  tubaires  en  evolution,  etc.     Revue  de  gyn.. 
1902,  vi.  51-84. 

Croft.  An  Anomalous  Case  of  Ectopic  Pregnancy,  probably  Ovarian.  Trans.  London 
Obst.  Soc,  1900,  xlii.  316-323. 

Dakix.  Cast  from  the  Uterus  having  all  the  Characters  of  the  Decidual  Membrane 
Found  in  Connection  with  Ectopic  Gestation,  etc.  Trans.  Lond.  Obst.  Soc.  1897. 
xxxviii,  385-388. 

Dezeimeris.     Grossesses  extra-uterines.     Jour,  des  conn,  med.-chir..  Paris,  Dec.  1836. 

Dibot.     Quoted  by  Sanger.     Monatsschr.  f.  Geb.  u.  Gyn.,  1895.  i,  21-28. 

Dobbert.  Sechzig  Falle  in  friihen  Entwickelungsstadien  unterbrochener  Tubenschwan- 
gerschaften.    Archiv  f.  Gyn.,  1902.  lxvi.  70-123. 

Dorlaxd.     Repeated  Extra-uterine  Pregnancy.     Amer.  Jour.  Obst,,  1898,  xxxvii,  478-491. 


558  OBSTETRICS 

Duhrssen.     Ueber  operative   Behandlung,  insbesondere  die  vaginale   Coeliotoinie  bei 

Tubarschwangerschaft,  nebst    Bemerkungen   zur   Aetiologie   der  Tubarschwanger- 

schaft  und  Beschreibung  eines  Tubenpolypen.     Archiv  f.  Gyn.,  1897,  liv,  207-323. 
Emanuel.      Eiue   zwanzigjahre   getragene  Extrauterinschwangersehaft.      Centralbl.   f. 

Gyn.,  1894,  1306. 
Feeling.     Die  Bedeutung  der  Tubenruptur  und  des  Tubaraborts  fur  Verlauf,  Prognose 

und  Therapie  der  Tubarschwangerschaft.     Zeitschr.  f.  Geb.  u.  Gyn.,  1898,  xxxviii, 

67-100. 
Fraxck.     Ueber  Extrauterinschwangersehaft  mit  besonderer  Beriicksichtigung  der  Ova- 

rialgraviditat.     Centralbl.  f.  Gyn.,  1895,  545. 
Fraxz.     Ueber  Einbettung  u.  Wachstum  des  Eies  im  Eierstock.     Hegars  Beitrage  zur 

Geb.  u.  Gyn.,  1902,  vi,  70-81. 
Funck-Brentano.     Des  grossesses  uterines  survenant  apres  la  grossesse  extra-uterine. 

These  de  Paris,  1898. 
Futh.     Ueber  die  Einbettung  des  Eies  in  der  Tube.    Archiv  f.  Gyn.,  1901,  lxiii,  97-158. 
Geuer.     Ovarialschwangersehaft.     Centralbl.  f.  Gyn.,  1894,  391. 
Gilford.     Ovarian  Pregnancy.     British  Med.  Jour.,  1901,  ii,  963-964. 
Glitsch.    Zur  Aetiologie  der  Tubenschwangerschaft.     Archiv  f.  Gyn.,  1900,  lx,  385-425. 
Gottschalk.    Ein  Praparat  von  Ovarialschwangersehaft  aus  der  3.-4.  Woche  der  Gra- 
vidity,   Centralbl.  f.  Gyn.,  1886,  727. 
Ein  Lithokelyphopadion,  das  gleiehzeitig  als  Fall  von  reiner  Eierstocksschwangerschaf  t 

sehr  bemerkenswerth  ist.     Verhandlungen  der  deutschen  Ges.  f.  Gyn.,  1893,  304- 

305. 
Granville.     Graphic  Illustrations  of  Abortion  and  Diseases  of  Menstruation.     London, 

1834. 
Griffiths.     Note  on  the  Importance  of  a  Decidual  Cast  as  Evidence  of  Extra-uterine 

Gestation.     Trans.  London  Obst.  Soc,  1894,  xxxvi,  335-340. 
Gestation  in  the  Fallopian  Tube,  and  the  Structural  Changes  that  take  Place  in  its 

Walls.    Jour,  of  Pathology  and  Bacteriology,  1898,  v,  443-459. 
Gurgui.     Die  Ovarialschwangersehaft  vom  path.  anat.  Standpunkte.     Stuttgart,  1880, 

150. 
Gutzwiller.     Ein  Fall  von  gleichzeitiger  Extra-  und  Intrauteringraviditat.     Zusam- 

menstellung  und  Betrachtung  derartiger  Falle.      Archiv  f.  Gyn.,  1893,  xliii,  223-251. 
Harris.     Operation  of  Primary  Laparotomy  in  Cases  of  Extra-uterine  Pregnancy,  with  a 

Tabular  Record  showing  the  Results  in  27  Women  under  26  Operators.     Amer. 

Jour.  Obst.,  1887,  xx,  1154-1167. 
Weitere  Fortschritte  der  Entbindung  ektopischer  lebensfahiger  Friichte  durch  Koelio- 

tomie.     Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  vi,  137-156. 
Hecker.     Beitrage  zur  Lehre  von  der  Schwangerschaft  ausserhalb  der  Gebarmutterhohle. 

Monatsschr.  f.  Geburtsk.,  1859,  xiii,  81-123. 
Hein.     Eierstoekschwangerschaft.     Archiv  f.  path.  Anat,  u.  Physiol.,  1847,  i.  513-537. 
Heinsius.     Beitrage  zur  Lehre  von  der  Tubengraviditat,  etc.     Zeitschr.  f.  Geb.  u.  Gvn.. 

1901,  xlvi,  385-434. 
Ueber  tubare  Einbettung  des  menschlichen  Eies.     Monatsschr.  f.  Geb.  u.  Gyn.,  1902, 

xv,  315-322. 
Henxig.     Die  Krankheiteu  der  Eileiter  und  die  Tubenschwangerschaft,     Stuttgart,  1876. 
Hexxigsen.     Abdominalschwangerschaft  bei  einer  Sechstgebarenden.     Archiv  f.  Gyn., 

1870,  i,  33.5-340. 
Hexrotix  et  Herzog.     Anomalies   du  canal  de   Miiller  comme  cause  des  grossesses- 

ectopiques.     Revue  de  gyn.,  1898,  633-649. 
Herman.     On  Delivery  by  the  Vagina  in  Extra- uterine  Gestation.     Trans.  London  Obst. 

Soc,  1887,  xxix,  429-455. 
Herzfeld.    Ueber  einen  Fall  von  Ovarialgraviditat,  uterine  Schwangerschaft.     Laparo- 

tomie.     Heilung.     Wiener  klin.  Wochenschr.,  1891,  Nr.  43,  802-804. 


EXTRA-UTERINE   PREGNANCY  559 

IIofmeiek.    Zur  Kenntniss  dera  normalen  [Jterusschleimbaut.    CentralbL  1'.  Gyn.,  L898, 

Nr.  33,  764-766. 
Hiuenkerger.    Bericht  aus  ik'in  IKbammen-InstituI   in  Moskau.    St.  Petersburg,  1863, 

122. 

Janvrin.     A  Case  of  Tubal  Pregnancy  of  Unusual  Interest.     Trans.  Amer.  Gyn, 

1886,  xi,  471-484. 
Kelly.     The  Treatment  of  Extra-uterine  Pregnancy  ruptured  in  the  Karlv  Months  by 

Vaginal  Puncture  and  Drainage.     Trans.  Amer.  Gyn.  Soc,  1896,  xxi,  190-309. 
KorwKu.     Fall  Vdii   Schwangersehaft  im  Graaf'schen  Follikel.     Centralbl.  f.  Cyn.,  1897, 

1426. 
Kreisch.    Beitrag  zur  Anatomie  und  Pathologie  der  TubargraviditSt.    Monatsschr.  f. 

Geb.  u.  Gyn.,  1899,  ix,  794-812. 
Kichexmeister.     Ueber  Lithopadion.     Arehiv  f.  Gyn.,  1881.  xvii,  153-359. 
Ki'iixE.     Beitrag  zur  Anatomie  der  Tubenschwangerschai't.     Marburg,  1899. 
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Ueber   Extrauterinschwangerschaft.     Volkmann's  Sammlung  klin.  Vortrage,  N.  F., 

1899,  Nr.  244-245. 
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Gyn.,  1891.  xxxix,  273-290. 
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u.  Gyn.,  1902,  xv,  48-71. 
Larsen.     See  Tainturier. 
Leopold.     Zur   Lehre   von    der    Graviditas   interstitialis.     Arehiv   f.  Gyn.,   1878,  xiii, 

355-365. 
Ovarialschwangerschaft   mit   Lithopadionbildung  von  35-jahriger   Dauer.     Arehiv  f. 

Gyn.,  1882,  xix,  210-218. 
Beitrage  zur  Graviditas  extrauterina.     1.  Graviditas  interstitialis.     2.  Graviditas  auf 

der.Fimbria  ovarica  bez.  Plica  inf  undibulo-ovarica.     3.  Graviditas  ovarialis.    Arehiv 

f.  Gyn.,  1899,  lviii.  526-565. 
Beitrag  zur  Graviditas  extra-uterina.     4.  Die  Graviditas  tubo-ovarialis.     Arehiv  f. 

Gyn.,  1899,  lix,  557-594. 
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Wiener  klin.  Wochenschr.,  1896,  Nr.  27,  600-604. 
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Ueber  die  Richtung  der  Flimmerbewegung  im  menschlichen  Uterus.     Centralbl.  f. 

Gyn.,  1898,  Xr.  13,  323-328. 
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Geb.  u.  Gyn.,  1892,  xxiii,  179. 
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560  OBSTETRICS 

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Conception    durch    ein    accessorisches   Tubenostium.      Kaiserschnitt  bedingt    durch 

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Toth.     Beitrage  zur  Frage  der  ektopisehen  Sehwangerschaft.     Archiv  f.  Gyn.,  1896,  li, 

410-482. 
Teuffel.      Hydramnion  bei  Extrauterinschwangerschaft.      Archiv  f.  Gyn.,  1884,  xxii, 

57-64. 
Tussenbroek-.     Un  cas  de  grossesse  ovarienne  (Grossesse  dans  un  Follicule  de  Graaf). 

Annales  de  Gyn.,  1899,  lii,  537-573. 


EXTRA  UTERINE   PREGNANCY  561 

1'iim:.    Graviditas  ovarii.     Monatsschr.  r.  Geburtsk.,  is.');,  s,  339  342. 

Varnier.     Recidive  de  grossesse  ectopique.    Comptes  rendus  Soc.  d'obst.  de  gyn.,  el  de 

psed.  de  Paris,  L900,  ii,  396  301. 
Veit.     Die  Eileiterschwangerschaft.    Stuttgart,  1884. 
Velpeau.    Trait6  complet  de  l'ari  des  accouchements.     Paris,  L835,  t.  i,  214. 
Voigt.    Schwtiiigorsi-liiil't   a  ill'  dor  Fimbria  ovarica.     Monatsschr.  f.  Geb.  u.  Gyn.,  1898 

viii.  222-2:!2. 
Walter,     Einige  Beobaehtungen   iiber  Schwangersobafl    ausserhalb  der  Gebfirmutter. 

.Monatsschr.  f.  Geburtsk.,  1S61,  xvii. 
Webster.    Ectopic  Pregnancy.     Edinburgh  and  London,  1895. 
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Nrs.  1,  2,  3. 
Wenzel.     Blasenmole  ira  Eileitcr.    Alte  Erfahrungen  iin  Lichte  der  neuen  Zeit,  Wies- 
baden, 1893,  85-89. 
Werth.     Beitrage   zur  Anatomie    und   zur  operativen   Behandlung  der  Extrauterin- 

schwangerschaft.    Stuttgart,  1887. 
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Tubes.     Amer.  Jour.  Med.  Sciences,  October,  1891. 
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325-407. 
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der  tubaren  Placenta.    Zeitschr.  f.  Geb.  u.  Gyn.,  1893,  xxvi,  78-143. 
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623-646. 
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kologie,  1891,  xli.  1-61. 


PATHOLOGY    OF    LABOUR 

CHAPTER   XXXI 
DYSTOCIA   DUE   TO  ANOMALIES  OF   THE  EXPULSIVE  FORCES 

Dystocia  or  difficult  labour  may  be  due  to  various  getiological  factors, 
and  is  most  commonly  encountered  in  the  following  groups  of  cases:  (1) 
Those  in  which  the  expulsive  forces  are  subnormal  and  are  not  sufficiently 
strong  to  overcome  the  natural  resistance  offered  to  the  birth  of  the  child 
by  the  bony  canal  and  the  maternal  soft  parts.  (2)  Those  in  which,  al- 
though the  expulsive  forces  may  be  of  normal  strength,  abnormalities  in 
the  structurejjLU.r-haTa.r-tpr  of  the  birth  canal  offer  an  insuperable  mechanical 
obstacle  to  the  descent  of  the  presenting  part.  (3)  Those  in  which  the 
foetus,  on  account  of  faulty  presentation _Q£-ftscessive  development,  cannot 
be  extruded  by  the  vis  a  tergo.  (4)  Those  ca^es  in  which  accidental  com- 
plications, such  as  eclampsia,  haemorrhage,  or  rupture  of  tile  uterrr^lead  to 
various  irregularities  which  interfere  with  the  normal  progress  of  labour. 

Dystocia  due  to  Anomalies  of  the  Expulsive  Forces. — The  expulsion  of 
the  foetus  is  brought  about  by  the  contractions  of  the  uterus,  re-enforced 
towards  the  latter  half  of  the  second  stage  of  labour  by  the  action  of  the 
muscles  of  the  abdominal  wall.  Either  of  these  factors  may  be  lacking  in 
force  or  intensity,  while  occasionally  they  may  be  abnormally  strong. 

Unfortunately,  there  is  no  absolute  standard  by  which  the  character 
of  the  labour  pains  can  be  gauged.  Thus,  in  many  multiparous  women 
a  rapid  and  happy  termination  of  labour  not  uncommonly  follows  a  few 
relatively  slight  pains,  which  in  primiparse  would  prove  quite  inadequate 
to  bring  about  the  desired  result.  Clinically  the  efficiency  of  the  uterine 
contractions  may  be  measured  by  their  effect  upon  the  course  and  duration 
of  labour,  provided  there  is  no  serious  mechanical  obstacle  to  be  overcome, 
so  that,  other  things  being  equal,  prolonged  or  precipitate  labour  occurs  as 
a  result  of  abnormalities  in  their  frequency  and  intensity. 

Prolonged  Labour. — Normally,  in  the  early  stages  of  labour,  the  uterine 
contractions  occur  at  infrequent  intervals,  and  gradually  increase  in  fre- 
quency, intensity,  and  duration  as  its  termination  is  approached.  More- 
over, a  proper  alternation  between  the  contraction  and  relaxation  of  the 
uterus  is  a  very  important  requisite  for  the  successful  accomplishment  of 
delivery. 

Anomalies  are  often  noted  in  the  first  stage  of  labour,  the  contractions 
recurring  in  some  patients  at  frequent  intervals  and  being  cramp-like  in 
character  and  very  painful,  but  exerting  very  little  influence  upon  the  dila- 
562 


DYSTOCIA  DUE  TO   ANOMALIES  OF  THE    EXPULSIVE    FORCES    563 

fcatioB  of  the  cervix  and  the  expulsioD  of  the  child.  As  a  result,  oblitera- 
tion of  the  cervical  canal  is  brought  aboul  very  slowly,  and  the  external  os 
undergoes  bu1  little  change.  As  a  rule,  such  conditions  do  no!  give  rise  to 
serious  complications,  -nice  under  appropriate  treatmenl  the  pains  assume 
a  more  normal  character,  after  which  the  termination  of  Labour  is  speedily 
accomplished. 

More  frequently,  however,  the  first-stage  pains  recur  at  long  inter- 
vals and  arc  feeble  in  character,  so  that  labour,  instead  of  being  termi- 
nated within  the  usual  period,  may  drag  <>n  for  days.  If  the  membranes 
are  unruptured  and  the  patient  is  in  good  condition,  the  delay  may  be 
regarded  with  equanimity,  since  in  the  great  majority  of  instances  the 
pains  eventually  become  stronger  and  more  frequent,  when  the  birth  of  the 
child  is  effected  without  interference.  For  this  reason,  the  obstetrician 
should  not  interfere  too  hastily,  but  should  encourage  the  patient  to  bear 
her  suffering  patiently  by  a  plain  statement  of  the  facts  of  the  case,  and 
the  assurance  that  a  favourable  outcome  may  be  expected  not  only  for  her 
but  also  for  the  child. 

Again,  labour  sometimes  begins  in  a  perfectly  typical  manner  and  gives 
every  promise  of  an  ordinarily  speedy  termination,  and  yet  after  a  certain 
lapse  of  time,  without  any  appreciable  cause,  the  pains  become  less  fre- 
quent and  less  intense,  although  giving  rise  to  quite  as  much  or  even  more 
suffering  than  previously.  At  the  same  time,  the  cervix,  which  was  becom- 
ing" obliterated  and  dilated  in  a  satisfactoiy  manner,  ceases  to  make  further 
progress,  and  labour  apparently  comes  to  a  standstill.  Such  a  condition  is 
frequently  due  to  what  is  termed  inertia  uteri. . 

In  all  of  these  cases,  the  prolongation  of  labour  is  commonly  attributed 
to  the  imperfect  dilatation  of  the  cervix,  which  is  supposed  to  be  due  to 
an  ajmormalidgiditv  of, its  tissue^.  Ordinarily,  however,  the  converse  is 
true,  and  the  conation  is  the  direct  result  of  faulty  uterine  contractions. 
That  this  latter  view  is  correct,  is  shown  by  the  fact  that  the  appearance  of 
satisfactory  contractions  is  promptly  followed  by  rapid  dilatation  of  the 
cervix  and  a  happy  termination  of  labour.  On  the  other  hand,  however, 
especially  in  primipara?  of  thirty  years  of  age  or  over,  excessive  rigidity  of  the 
cervix  and  its  consequent  tardy  and  imperfect  dilatation  may  be  the  essential 
factor  in  the  production  of  the  dystocia,  especially  when  a  further  complica- 
tion has  been  introduced  by  the  premature  rupture  of  the  membranes. 

This  accident  occurs  occasionally  in  primipara?,  and  not  infrequently  in 
multiparous  women  before  the  onset  of  uterine  contractions,  and  gives  rise 
to  what  is  designated  as  "  dry  labour/'  which  is  usually  unduly  prolonged  and 
very  painful.  The  delay  is  due  in  great  part  to  the  absence  of  the  hydro- 
static action  of  the  bag  of  waters,  in  consequence  of  which  the  changes  in  the 
cervix  must  be  brought  about  almost  entirely  by  the  direct  pressure  of  the 
presenting  part,  which  acts  as  a  dilating  wedge  of  imperfect  shape  and  con- 
sistency. 

This  complication  is  usually  not  so  serious  in  multiparous  as  in  primip- 
arous  women,  since  in  the  former  labour,  as  a  rule,  sets  in  within  a  short 
time  after  the  discharge  of  the  liquor  amnii.    Occasionally,  however,  hours, 
days,  and  in  rare  instances  even  weeks  may  elapse  before  it  occurs. 
37 


564  OBSTETRICS 

Not  uncommonly  obliteration  of  the  cervical  canal  takes  place  without 
difficulty,  while  the  external  os  alone  appears  to  offer  the  obstacle  to  dilata- 
tion. In  such  cases  "its  margins  are  often  extremely  thin  and  sharp  and 
during  a  contraction  may  not  exceed  a  sheet  of  paper  in  thickness.  On  the 
other  hand,  especially  when  labour  is  unduly  prolonged,  they  may  become 
thick  and  cedematous. 

In  the  absence  of  any  mechanical  obstacle,  prolongation  of  the  second 
stage  of  labour  is  rarely  due  to  abnormalities  in  the  uterine  contractions, 
but  rather  to  deficient  action  of  the  abdominal  muscles.  In  primiparous 
women,  especially,  the  tardy  labour  is  often  ascribed  to  the  resistance 
offered  by  a  rigid  peringeum  and  a  small  vaginal  outlet,  but  in  the  majority 
of  cases  this  is  only  apparent,  the  delay  being  really  due  to  an  insufficient 
vis  a  tergo. 

JEtiology. — Uterine  insufficiency  is  usually  attributed  to  one  of  three 
/|  causes:  faulty  development  or  diseased  conditions  of  the  uterine  muscula- 
ture,  anomalies  in  its  innervation,  or  mechanical  interference  with  its  con- 
'  traction.  The  first  factor  is  the  one  most  frequently  concerned  in  the 
'  causation  of  tardy  labour,  and  is  especially  likely  to  be  associated  with 
imperfect  general  development,  being  frequently  observed  in  patients  pre- 
senting varieties  of  the  justo-minor  pelvis,  but  only  rarely  in  sufferers  from 
rhachitic  deformities.  On  the  other  hand,  faulty  development  of  the  mus- 
culature is  occasionally  noted  in  apparently  normal  women,  and  is  relatively 
common  in  large,  pale,  and  corpulent  individuals. 

Sometimes  the  faulty  action  of  the  uterine  muscle  is  attributable  to 
a  loss  of  tonicity  incident  to  excessive  distention,  and  is  therefore  fre- 
quently met  with  in  women  who  have  passed  through  a  number  of  preg- 
nancies in  rapid  succession,  or  in  whom  the  uterus  has  been  subjected  to 
acute  distention,  as  in  certain  cases  of  multiple  pregnancy  and  hydramnios. 
Much  less  commonly  the  defect  is  due  to  general  weakness  following  ex- 
hausting diseases,  but  that  this  is  rarely  responsible  is  shown  by  the  com- 
mon observation  that  the  pains  are  usually  very  efficient  even  in  patients 
suffering  from  advanced  stages  of  tuberculosis. 

Although  direct  proof  of  the  existence  of  abnormalities  in  the  innerva- 
tion of  the  uterine  musculature  cannot  be  adduced,  clinical  observation 
affords  strong  presumptive  evidence  in  favour  of  this  view,  or  at  least 
indicates  clearly  the  possibility  that  extraneous  causes  can  interfere  re- 
flexly  with  the  activity  of  the  uterus.  Thus,  it  is  a  matter  of  common 
experience  that  the  entrance__oj  the_obstetrician  into  the  lying-in  chamber 
is  frequently  followed  by  a  cessation  of  the  labour  pains,  which  is  generally 
transient,  but  sometimes  persists  for  quite  a  long  while.  Moreover,  extreme 
nervousness,  profound  mental  emotions,  or  excruciating  pain  mav  have  a 
similar  effect.  In  such  cases  the  severe  pain  is  often  due  to  the  irregular 
action  of  the  uterus,  and  in  turn,  by  acting  reflexly,  interferes  still  fur- 
ther with  its  function,  thus  giving  rise  to  a  vicious  circle.  That  reflex 
nervous  influences  are  responsible  is  shown  by  the  fact  that  the  administra- 
tion of  a  sedative  is  frequently  followed  by  a  return  of  satisfactory  con- 
tractions. 

That  the  action  of  the  uterus  is  occasionally  influenced  by  mechanical 


DYSTOCIA    DUE  TO   ANOMALIES  OP  THE   EXPULSIVE   FORCES    565 

conditions  is  shown  by  the  cases  in  which  tumour  formations  in  its  wall, 
especially  mypmata,  have  been  round  to  be  responsible  for  faulty  labour 
pains.  Muchtlic  saTTic  cll'ect  is  exerted  hy  uterine  displacements,  especially 
when  the  organ  sags  markedly  forward  in  a  pendulous  abdomen.  Old  ad- 
hesions about  the  uterus  and  appendages,  and  fresh  inflammatory  area-  in 
the  same  location  may  act  in  a  similar  manner. 

Defective  abdominal  contractions  may  be  due  to  a  number  of  causes. 
Sometimes  the  insufficiency  results  from  fj^kv_developmcnt  of  the  ab- 
dominal muscles,  but  more  frequently  is  due  to  a  lo^g__of  muscular  tone 
following  excessive  distention,  so  that  it  is  much  more  common  m  tnultip- 
arous  than  in  primiparous  women.  \oi  infrequently  the  insufficiency  is 
only  apparent,  and  is  due  to  the  fact  that  for  fear  of  increased  pain  the 
patient  is  unwilling  to  bring  her  abdominal  muscles  into  full  play,  and 
makes  efforts  to  restrain  them.  For  this  reason  the  obstetrician  is  often 
obliged  to  terminate  labour  by  means  of  low  forceps,  although  he  feels  sure 
that  a  few  minutes'  effective  use  of  the  abdominal  muscles  would  lead  to 
spontaneous  delivery.  In  many  such  cases  the  administration  of  chloro- 
form is  attended  by  most  happy  results,  since  it  dulls  the  sensation  of  pain  / 
sufficiently  to  enable  the  patient  to  bring  her  abdominal  muscles  into  action.  \ 

Treatment  of  Prolonged  Labour. — Active  treatment  is  rarely  demanded 
when  the  tardy  labour  is  the  result  of  infrequent  pains  of  slight  intensity,  as 
in  the  majority  of  such  cases  they  gradually  become  more  severe  and  eventu- 
ally bring  about  a  spontaneous  delivery.  If  the  condition  lasts  for  several 
days  it  is  important  that  the  patient  should  sleep  veil  at  night,  and  the  ad-i 
ministration  of  hypnotics,  or  even  of  niqrphineJivpodermicallv.  is  indicated,  i 

On  the  other  hand,  when  the  pains  are  inefficient,  cramp-like,  and  fol- 
low one  another  in  rapid  succession  without  exerting  any  appreciable  effect 
upon  the  course  of  labour,  excellent  results  often  follow  the  administra- 
tion of  a  hypodermic  injection  of  mornhine  (grain  ^),  combined  with  the 
sulphate  of  atropine  (grain  tIo")"  or  a  rectal  injection  containing  30  grains 
of  chloral  hydrate*  in  4  ounces  of  warm  milk  may  be  given,  and  repeated,  if 
necessary,  in  one  hour. 

"When  the  dystocia  is  due  to  secondary  uterine  inertia  the  problem  is 
more  difficult;  though,  as  a  rule,  if  the  patient  can  obtain  several  hours  of 
sound  sleep,  more  satisfactory  pains  will  appear  when  she  wakens.  For  this 
reason  the  use  of  a  hypnotic  is  often  indicated.  Some  authors  recommend 
the  administration  of  quinine  in  this  class  of  cases.  It  would  appear,  how- 
ever, that  the  oxytocic  properties  of  the  drug  have  been  a  good  deal  ex- 
aggerated, since  in  many  cases  large  doses  produce  no  visible  effect.  Occa- 
sionally, however,  5  grains  of  the  sulphate  given  in  a  freshly  prepared  pill 
or  in  solution,  and  repeated  in  one  hour,  may  prove  of  great  benefit.  A 
third  dose  is  not  necessary,  for,  if  the  uterus  has  not  responded  to  the 
amount  already  given,  the  further  administration  of  the  drug  may  be 
regarded  as  useless. 

Ergot  was  formerly  used  with  a  free  hand  in  this  condition,  but  this 
practice  cannot  be  too  strongly  reprehended.  It  is  true  that  its  administra- 
tion is  often  followed  by  an  increase  in  the  intensity  of  the  uterine  contrac- 
tions, but  experience  has  shown  that  they  soon  lose  their  normal  charac- 


566  OBSTETRICS 

teristics  and  become  tetanic.  As  a  result  the  uterus  is  liable  to  remain 
firmly  contracted  upon  its  contents,  and  no  longer  alternating  between 
contraction  and  relaxation,  loses  its  expulsive  power,  so  that  the  final  action 
of  the  drug  is  to  defeat  the  very  purpose  for  which  it  was  given.  Moreover, 
if  the  existence  of  a  mechanical  obstacle  has  been  overlooked,  the  use  of 
ergot  may  lead  to  so  pronounced  an  overstretching  of  the  lower  uterine 
segment  that  rupture  occurs.  From  the  very  first  the  young  physician 
should  make  up  his  mind  never  to  employ  ergot  for  its  oxytocic  properties, 
and  to  use  it  only  as  a  prophylactic  for  uterine  haemorrhage  after  the  expul- 
sion of  the  placenta. 

As  has  already  been  pointed  out,  abnormalities  in  the  contraction  of 
the  uterus  are  usually  associated  with  imperfect  dilatation  of  the  cervix, 
and  in  elderly  primiparae,  and  occasionally  in  younger  women  who  have 
suffered  from  inflammatory  conditions  about  the  cervix,  rigidity  of  the  tis- 
sues can  sometimes  be  invoked  as  its  underlying  cause.  In  many  cases  the 
administration  of  a  sedative  is  followed  by  satisfactory  results.  The  use  of 
an  anaesthetic,  although  it  frequently  leads  to  satisfactory  dilatation  of  the 
cervix,  is  generally  inadvisable,  inasmuch  as  the  patient,  having  once  experi- 
enced its  soothing  effect,  refuses  to  dispense  with  it,  so  that  the  obstetrician 
will  often  be  obliged  to  continue  its  use  throughout  the  entire  second 
stage,  thereby  so  prolonging  labour  that  the  application  of  forceps  becomes 
necessary.  Occasionally  a  copious  vaginal  douche  of  hot  sterile  salt  solu- 
tion or  a  hot  full  bath  is  attended  by  satisfactory  results. 

In  other  cases,  if  interference  becomes  imperative,  the  introduction  of 
a  bougie  into  the  uterus,  or  the  employment  of  a  small  Champetier  de 
lUbes^rfrbber  bag  acts  as  an  efficient  uterine  irritant,  and  brings  about 
complete  dilaTaTTolr.  As  a  rule,  however,  if  the  condition  of  the  mother  or 
the  child  demands  the  prompt  termination  of  labour,  rapid  dilatation  of 
the  cervix  is  best  effected  manually  by  Harris's  method,  provided  the  inter- 
nal os  and  cervical  canal  are  already  obliterated. 

When  labour  is  complicated  by  premature  rupture  of  the  membranes, 
the  patient  should  be  informed  concerning  its  probable  effect,  and  should 
be  encouraged  to  bear  her  sufferings  as  patiently  as  possible.  At  the  same 
time  she  should  be  most  carefully  watched,  and  care  should  be  taken  that 
the  child's  head  is  not  subjected  for  too  long  a  time  to  injurious  pressure. 
Moreover,  the  premature  opening  up  of  the  amnion  greatly  increases  the 
danger  of  intrapartum  jnf ecstion.  Accordingly,  if  symptoms  of  exhaustion 
appear,  and  an  objective  examination  shows  that  the  mother  or  child  will 
suffer  from  further  delay,  interference  is  indicated,  particularly  if  the  tem- 
perature becomes  elevated,  or  changes  in  the  fcetal  pulse-rate,  the  passage 
of  meconium  or  a  markedly  cedematous  condition  of  the  cervix  be  noted. 
Under  such  circumstances  dilatation  may  be  effected  either  by  means  of 
the  rubber  bag  or  manually,  after  which  delivery  should  be  brought  about 
as  soon  as  possible  by  the  most  conservative  method  available.  Forceps, 
however,  should  never  be  applied  until  the  cervix  is  completely  dilated, 
nor  while  the  head  is  freely  movable  above  the  superior  strait. 

Tardy  labour,  due  to  the  prolongation  of  the  second  stage,  is  usually  best 
treated  by  the  application  of  forceps,  except  in  those  cases  in  which  there  is 


DYSTOCIA    DUE   TO   ANOMALIES   OF   THE    EXPULSIVE    FoUchS     5«>7 

some  mechanical  obstacle,  <>i-  when  the  patient  refuses  to  use  her  abdominal 
muscles.  In  the  hitler  ease  the  necessity  for  instrumental  delivery  may 
often  he  obviated  by  the  judicious  administration  of  chloroform. 

Precipitate  Labour. — Precipitate  labour  may  result  Erom  an  abnormally 
slighj  degree  of  resistance  offered  by  the  soft  parts,  as  in  certain  multip- 
arous  women,  or  from  abnormally  strong  uterine  and  abdominal  contrac- 
tions. 

Generally  speaking,  precipitate  labour  is  not  attended  by  serious  con- 
sequences, although  the  child  is  sometimes  extruded  so  rapidly  that  the 
patient  is  unable  to  secure  proper  attention.  Under  such  circumstances  deep 
tears  of  the  perinaeum  are  common.  Cases  are  on  record  in  which  the 
woman  has  been  suddenly  overtaken  by  intense  labour  pains  and  has  given 
birth  to  the  child  before  she  could  reach  her  bed.  Under  such  circumstances 
the  child  has  sometimes  fallen  to  the  ground  and  sustained  severe  or  even 
fatal  injuries.  Occasionally  the  cord  is  torn  through  and  the  child  may 
bleed  to  death  before  aid  is  obtainable. 

If  tempestuous  pains  come  on  while  the  patient  is  under  the  observation 
of  a  physician,  they  should  be  controlled  by  the  administration  of  chloro- 
form, in  order  that  the  head  may  be  held  back  and  prevented  from  being 
born  too  brusquely.  The  effects  of  precipitate  labour  have  been  studied 
particularly  by  Winckel. 

Tetanic  Contract  wmzf  the  Uterus. — Occasionally  in  the  first,  and  more 
frequently  in  the  second  stage  of  labour,  the  uterus  may  cease  to  relax  at 
regular  intervals,  and  remain  in  a  condition  of  continued  or  tetanic  contrac- 
tion. This  condition  is  usually  encountered  in  prolonged  labours,  in  which 
a  mechanical  obstacle  is  opposed  to  the  passage  of  the  child.  In  such  cases 
the  danger  of  rupture  of  the  uterus  becomes  imminent,  although  now  and 
again  this  accident  occurs  when  everything  seems  to  be  going  on  normally. 

So  long  as  the  tetanic  condition  persists  the  extrusion  of  the  contents 
of  the  uterus  is  out  of  the  question,  while  at  the  same  time  the  patient 
suffers  intense  pain,  and  the  child  is  exposed  to  considerable  danger,  owing 
to  interference  with  the  placental  circulation.  If  the  condition  is  not  due 
to  an  obstruction  it  can  be  temporarily  controlled  by  the  administration  of 
sedatives  or  an  anaesthetic,  after  which  delivery  should  be  effected  as  soon 
as  practicable. 

Closely  related  to  this  form  of  dystocia  is  that  which  is  sometimes  attrib- 
uted to  a  stricture  resulting  from  tonic  contraction  of  Bandl's  ring.  Consid- 
erable attention  has  been  directed  to  this  complication  within  the  last  few 
years,  and  numerous  cases  have  been  described  by  Budin,  Demelin,  Cheron, 
Rossa,  and  others.  The  French  observers  believe  that  while  the  portions  of 
the  uterus  above  and  below  it  remain  flaccid,  Bandl's  ring  can  undergo  iso- 
lated contraction,  and  thereby  so  strongly  compress  the  neck  or  some  other 
portion  of  the  child  as  to  interfere  seriously  with  its  delivery.  Cheron  has 
reported  instances  of  transverse  presentation  in  which  this  kind  of  stricture 
developed  and  confined  the  child  to  the  upper  portion  of  the  uterus,  at  the 
same  time  offering  an  almost  insuperable  obstacle  to  the  introduction  of 
the  hand  for  the  performance  of  version. 

Veit  is  probably  correct  in  denying  the  existence  of  such  conditions. 


568  OBSTETRICS 

and  in  believing  that  the  reports  are  due  to  faulty  observation.  That  the 
contraction  should  be  confined  to  Bandl's  ring  would  appear  highly  im- 
probable, and  it  is  much  more  likely  that  the  entire  active  portion  of  the 
uterus  may  pass  into  a  condition  of  tetanic  rigidity,  and  that  under  such 
circumstances  its  lower  margin  would  be  felt  as  a  contracted  ring.  In  ssch 
cases  the  lower  uterine  segment  would  be  flabby,  while  the  upper  portion  of 
the  uterus  would  be  tightly  contracted,  thereby  opposing  a  serious  obstacle 
to  the  expulsion  of  the  child  and  to  the  introduction  of  the  hand  or  instru- 
ments into  the  uterus.  In  cases  of  this  character  the  administration  of  an 
anaesthetic  relaxes  the  spasmodic  contractions,  and  delivery  can  then  be 
accomplished  by  the  most  appropriate  procedure. 

It  is  likewise  probable  that,  in  a  certain  number  of  cases  in  which  the 
dystocia  has  been  attributed  to  the  contraction  of  Bandl's  ring,  the  condi- 
tion was  really  due  to  more  or  less  rigidity  of  the  internal  os,  while  the 
cervical  canal  below  it  had  undergone  satisfactory  dilatation. 

As  the  result  of  the  misuse  of  ergot  or  of  extensive  adherence  of  the  pla- 
centa, the  uterus  sometimes  undergoes  such  an  extreme  degree  of  retraction 
during  the  third  stage  that  the  latter  becomes  imprisoned  in  its  cavity.  In 
such  cases  the  greater  part  of  the  upper  segment  of  the  uterus  is  tightly  con- 
tracted over  the  retained  placenta,  while  its  lower  portion  undergoes  still 
further  retraction,  and  is  felt  by  the  examining  finger  as  a  tightly  contracted 
ring  below  the  placenta.  The  lower  uterine  segment  and  the  cervix,  not 
having  recovered  from  the  distention  to  which  they  have  been  subjected,  are 
flabby  in  character,  and  widen  from  above  downward  to  the  vaginal  insertion. 
From  the  shape  thus  imparted  to  the  uterus  the  condition  is  generally  desig- 
nated as  an  "hour-glass  contraction."  Its  occurrence  usually  necessitates 
the  manual  removal  of  the  placenta,  which  can  sometimes  be  accomplished 
only  under  anaesthesia. 

LITERATURE 

Budin.     De  la  dystocie  causee  par  l'anneau  de  Bandl.     L'Obstetrique,  1898,  iii,  289-310. 
Cheron.     Des  difficulties  de  la  version  causees  par  la  retraction  de  l'anneau  de  Bandl. 

These  de  Paris,  1899. 
Demelin.     De  la  retraction   uterine   avant  la  rupture  des  membranes.     L'Obstetrique, 

1898,  iii,  49-59. 
Rossa.     Der  Contractionsring  in  seinen  Beziehungen  zur  Mechanik  der  Geburt.    Monats- 

schr.  f.  Geb.  u.  Gyn..  1900,  xii.  457-480. 
Veit.     Ueber  die   Dystocie  durch  den  Contractionsring.     Monatsschr.  f.  Geb.  u.  Gyn., 

1900,  xi,  493-501. 
Winckel.     Ueber  die  Bedeutung  pracipitioter  Geburten  fiir  die  Aetiologie  des  Puerperal- 

fiebers.     Miinchen,  1884. 


CHAPTEE   XXXII 

DYSTOCIA  DUE   TO  ABNORMALITIES  OF   THE   GENERATIVE 

TRACT 

Vulva. — Complete  atresia,  of  the  vulva  or  the  lower  portion  of  the 
vagina  is  usually  congenital,  and  unless  corrected  by  operative  measures 
would  oppose  an  insuperable  obstacle  to  conception.  Yon  Meer  has  reported 
an  exceptional  case  in  which  the  lower  two  thirds  of  the  vagina  were  lack- 
ing, while  the  upper  third  communicated  with  the  bladder.  Coitus  was 
accomplished  per  urethra m,  through  which  a  three-months'  foetus  was  sub- 
sequently expelled. 

More  frequently  vulval  atresia  is  incomplete,  and  is  due  to  adhesions  | 
and  cicatricial  changes  resulting  from  injury  or  inflammatory  processes.  J 
The  defect  may  offer  a  considerable  obstacle  to  labour,  but  the  resistance ' 
is  usually  overcome  by  the  continued  pressure  exerted  by  the  head,  though 
frequently  only  at  the  expense  of  deep  perineal  tears. 

Cases  are  on  record  in  which  an  almost  inrqerf oratejivmen  has  remained 
intact  until  the  time  of  labour,  and  only  ruptured  when  distended  by  the 
child's  head.  In  rare  instances,  as  was  pointed  out  by  Coester,  a  thick 
septate  hymen  may  form  a  bridge  of  tissue  opposing  the  advance  of  the 
presenting  part,  and  may  require  to  be  cut  through  before  delivery  can  be 
completed. 

In  some  women,  especially  in  elderly  primiparse,  the  vulval  outlet  is 
very  small,  rigid,  and  altogether  lacking  in  elasticity.  Again,  as  the  result 
of  pressure  oFrenal  lesions,  the  vulva  may  become  so  (Edematous  that  its 
orifice  is  almost  occluded.  The  latter  condition  does  not  necessarily  give 
rise  to  dystocia,  but  in  both  the  brittleness  of  the  soft  parts  predisposes  to 
perineal  laceration.  Moreover,  when  the  oedema  has  been  excessive,  and 
has  persisted  for  some  time,  the  tone  of  the  tissues  may  be  so  lowered  that 
they  even  become  gangrenous  as  a  result  of  the  strain  incident  to  labour. 

The  formation  of  thrombi  or  ha?matomata  about  the  vulva,  although 
more  common  during  the  puerperium,  occasionally  occurs  during  the  latter 
part  of  pregnancy,  and  gives  rise  to  a  slight  retardation  of  labour.  Inflam- 
matory lesions  about  the  vulva,  as  well  as  malignant  new  growths,  may  have 
a  similar  effect. 

Vagina. — Complete  vaginal  atresia  is  nearly  always  congenital  in  origin, 
and  is  an  effectual  bar  to  pregnancy.  Incomplete  forms,  on  the  other  hand, 
are  sometimes  manifestations  of  faulty  development,  but  more  frequently 
result  from  accidental  complications. 

569 


570  OBSTETRICS 

Somewhat  rarely  the  vagina  is  divided  into  two  halves  by  a  longitudinal 
septum  extending  from  the  vulva  to  the  cervix;  more  often  the  structure  is 
incomplete,  being  limited  to  either  the  upper  or  lower  portion  of  the  canal. 
Such  conditions  are  frequently  associated  with  abnormalities  in  the  develop- 
ment of  the  generative  tract,  and  their  detection  should  always  lead  to 
further  careful  examination,  with  a  view  to  determining  whether  the 
uterus  and  appendages  are  normal. 

A  complete  longitudinal  septum  rarely  gives  rise  to  dystocia,  as  the 
half  of  the  vagina  through  which  the  child  descends  gradually  undergoes 
satisfactory  dilatation.  On  the  other  hand,  an  incomplete  septum  occa- 
sionally interferes  with  the  descent  of  the  head,  becoming  stretched  over 
it  as  a  fleshy  band  of  varying  thickness.  Such  structures  are  usually  torn 
through  spontaneously,  but  occasionally  are  so  resistant  that  they  must 
be  severed  by  the  obstetrician. 

Occasionally  the  vagina  may  be  obstructed  by  ring-like  strictures  or 
bands  of  congenital  origin.  These,  however,  rarely  offer  a  serious- obstacle 
to  labour,  as  they  usually  yield  before  the  oncoming  head,  though  in  ex- 
treme cases  incision  may  be  necessary. 

Sometimes  the  upper  portion  of  the  vagina  is  separated  from  the  re- 
mainder of  the  canal  by  a  diaphragm-like  structure  with  a  small  central 
opening.  Such  a  condition  is  occasionally  mistaken  by  inexperienced  ob- 
servers for  the  vaginal  fornix,  and  at  the  time  of  labour  for  the  undilated 
external  os.  A  careful  examination,  however,  should  reveal  the  presence  of 
the  opening,  through  which  a  finger  can  be  passed,  the  cervix  then  being  dis- 
tinguished above  it.  After  the  external  os  is  completely  dilated,  the  head 
impinges  upon  the  abnormal  structure  and  causes  it  to  bulge  downward.  If 
it  does  not  yield,  slight  pressure  upon  its  opening  will  usually  lead  to  fur- 
ther dilatation;  but  if  this  is  not  effectual  crucial  incisions  may  be  neces- 
sary in  order  to  allow  of  delivery. 

Accidental  atresia  is  always  secondary  in  origin,  and  results  from  the 
formation  of  adhesions  following  injuries  or  inflammatory  processes.  It  not 
infrequently  follows  severe  puerperal  infections,  during  the  course  of  which 
the, entire  lining  of  the  vagina  may  have  sloughed  off,  so  that  as  healing 
occurs  its  lumen  has  become  almost  entirely  obliterated.  A  similar  result 
is  sometimes  noted  after  diphtheria,  small-pox,  cholera,  and  syphilis;  while 
in  rare  instances,  as  in  a  case  reported  by  Schenk,  it  may  be  due  to  the 
action  of  corrosive  fluids  injected  into  the  vagina  in  the  hope  of  inducing 
abortion.  That  the  most  frequent  cause  of  atresia  is  injury  or  inflammatory 
conditions  following  labour  is  shown  by  the  fact  that  209  of  the  1,000 
cases  collected  by  Neugebauer  presented  such  a  history. 

The  effects  of  such  conditions  vary  greatly.  In  the  majority  of  cases, 
owing  to  the  softening  of  the  tissues  incident  to  pregnancy,  the  obstruc- 
tion is  gradually  overcome  by  the  pressure  exerted  by  the  presenting  part; 
less  often  manual  or  hydrostatic  dilatation  or  incisions  may  become  neces- 
sary; while  in  very  rare  cases  extreme  dystocia  may  demand  Cesarean  sec- 
tion. Full  literature  concerning  this  complication  is  to  be  found  in  the 
articles  of  Ward  and  Brindeau. 

Among  the  rare  causes  of  serious  dystocia,  vaginal  neoplasms  are  worthy 


DYSTOCIA    DUB  TO   ABNORMALITIES   OF  THE  CERVIX  571 

of  mention.  Gilder,  in  L893,  having  collected  <><>  cases  from  the  Literature. 
The  obstruction  \\ as  due  to  the  presence  of  cysl ic  structures,  fibromata,  car- 
cinomata,  sarcomata,  or  hamiatomata,  arising  from  the  vaginal  walls  or 
the  surrounding  (issues.  When  the  tumour  is  accessible  it  is  best  treated 
by  excision,  no  matter  whal  its  origin.  II'  this  is  not  practicable,  and  the 
growth  is  cystic,  tapping  becomes  the  operation  of  choice.  The  presence  of 
a  solid  tumour  may  occasionally  afford  an  indication  for  Csesarean  section. 

Exceptionally  tetanic  contraction  of  the  levator  ani  muscle  may  seriously 
interfere  with  the  descent  of  the  head.  \n  this  condition,  which  is  analo- 
gous to  the  vaginismus  of  non-pregnant  women,  a  thick,  ring-like  structure 
completely  encircles  and  markedly  constricts  the  vagina  several  centimetres 
above  the  vulva.  In  a  recent  thesis  Davet  has  collected  a  number  of  such 
cases. 

Ordinarily  the  condition  yields  to  the  administration  of  sedatives  or 
anaesthetics,  though  in  one  of  my  patients  the  obstruction  persisted  in 
spite  of  profound  anaesthesia,  and  it  was  only  after  steady  pressure  had 
been  exerted  upon  it  for  ten  minutes  or  more  that  it  relaxed  sufficiently  to 
permit  the  passage  of  the  hand  folded  in  the  shape  of  a  cone. 

Cervix. — Inasmuch  as  complete  atresia  of  the  cervix  is  incompatible 
with  conception,  it  must  be  assumed,  whenever  such  a  condition  is  met 
with  in  a  pregnant  woman,  that  conception  had  occurred  before  its  forma- 
tion. In  the  majority  of  cases,  however,  the  atresia  is  only  apparent,  and 
is  simulated  by  a  very  minute  external  os. 

A  good  illustration  is  afforded  by  the  so-called  conglutinatio  orificii  ex- 
terni.  In  this  condition  the  cervical  canal  undergoes  complete  oblitera- 
tion at  the  time  of  labour,  while  the  os  remains  extremely  small  with  very 
thin  margins,  the  presenting  part  being  separated  from  the  vagina  only 
by  a  very  thin  layer  of  tissue.  Formerly,  this  appearance  was  attributed 
to  the  existence  of  adhesions  between  the  lips  of  the  external  os,  but 
Schroeder  was  probably  right  in  stating  that  it  is  simply  due  to  a  very 
small  and  resistant  os.  Ordinarily,  complete  dilatation  promptly  follows 
firm  pressure  with  a  finger  tip,  though  in  rare  instances  manual  dilatation 
or  crucial  incisions  may  become  necessary. 

rV^i/Wn£/j^»o£^j of  the  cervix  frequently  follows  difficult  labour  asso- 
ciated ^liconsKbrahle"  destruction  of  tissue.  Less  frequently  it  is  due  to 
syphilitic  ulceration  and  induration,  several  instances  of  which  have  been 
reported  by  Le  Bigot.  Now  and  again  it  results  from  the  employment  of 
corrosive  substances  for  the  purpose  of  producing  abortion. 

Ordinarily,  owing  to  the  softening  and  succulence  of  the  tissues  incident 
to  pregnancy,  the  stenosis,  whatever  its  cause,  gradually  yields  to  the  natu- 
ral forces;  but  in  other  cases  dilatation  has  to  be  accomplished  by  manual 
methods  or  by  the  employment  of  rubber  bags.  In  rare  instances,  how- 
ever, the  resistance  may  be  too  great  to  be  overcome,  and  as  labour  pro- 
gresses the  lower  uterine  segment  may  become  stretched  to  such  a  degree 
that  rupture  becomes  imminent,  an  accident  which  can  be  averted  only 
by  the  performance  of  Cesarean  section. 

Rigidity  of  Cervix. — Eef erence  has  already  been  made  to  the  unyielding 
cervix  of  elderly  primiparae.     Occasionally  still  greater  rigidity  is  encoun- 


572  OBSTETRICS 

tered  in  patients  who  have  suffered  from  inflammatory  lesions,  though  such 
conditions  rarely  give  rise  to  serious  dystocia?  On  the  other  hand,  in  cer- 
tain extreme  cases  of  hypertrophic  elongation  of  the  cervix,  considerable 
difficulty  is  experienced  in  effecting  dilatation,  although,  as  a  rule,  one  is 
surprised  to  see  how  completely  the  abnormality  may  be  effaced  during  the 
course  of  pregnancy. 

Dystocia  due  to  malformations  of  the  uterus  has  already  been  consid- 
ered in  Chapter  XXVII. 

Uterine  Displacements. — Anteflexion. — Marked  anteflexion  of  the  uterus 
is  usually  associated  with  a  pendulous  abdomen.  In  primiparse  the  condi- 
tion is  usually  indicative  of  disproportion  between  the  size  of  the  head  and 
the  pelvis;  whereas  in  multipara  it  is  more  often  the  result  of  extreme 
flaccidity  of  the  abdominal  walls  incident  to  repeated  childbearing.  In  the 
latter  class  of  cases  the  abnormal  position  of  the  uterus  prevents  the  force 
of  its  contractions  from  being  properly  transmitted  to  the  cervix,  hence 
the  dilatation  of  the  latter  is  interfered  with.  Marked  improvement  in  this 
respect  frequently  follows  the  application  of  a  properly  fitting  abdominal 
bandage,  by  means  of  which  the  uterus  is  maintained  in  an  approximately 
normal  position. 

Retroflexion. — As  was  said  in  Chapter  XXVII,  retroflexion  of  the  preg- 
nant uterus  is  usually  incompatible  with  advanced  pregnancy,  since,  if  spon- 
taneous or  artificial  reposition  does  not  occur,  the  patient  either  aborts  or 
presents  symptoms  of  incarceration  before  the  end  of  the  fourth  month. 
In  the  very  exceptional  instances  in  which  pregnancy  goes  on  to  term,  the 
fundus  remains  attached  to  the  floor  of  the  pelvis,  while  the  anterior  wall 
hypertrophies  to  such  an  extent  as  to  afford  room  for  the  product  of  con- 
ception. In  this  condition,  which  is  known  as  sacculation,  the  head  of  the 
child  occupies  the  fundus,  while  the  cervix  is  sharply  bent  and  so  drawn 
up  that  the  external  os  lies  above  the  upper  margin  of  the  symphysis  pubis. 
At  the  time  of  labour  the  contractions  tend  to  force  the  child  through  the 
most  dependent  portion  of  the  uterus,  while  the  cervix  dilates  only  partially, 
so  that  spontaneous  labour  is  out  of  the  question.  As  a  rule,  the  cervix 
can  be  dilated  manually  under  anaesthesia,  and  the  child  delivered  by  ver- 
sion; but  in  rare  instances  the  cervix  is  so  inaccessible  that  Cesarean  section 
will  afford  the  most  conservative  method  of  delivery. 

Dystocia  Due  to  Operations  for  the  Relief  of  Retroflexion  of  the  Uterus. 
— Unfortunately,  several  of  the  operations  which  have  been  suggested  for 
the  relief  of  retroflexion  of  the  non-pregnant  uterus,  while  rectifying  the 
condition,  occasionally  give  rise  to  serious  dystocia.  Thus,  in  rare  instances, 
after  a  ventrofixation,  when  the  fundus  has  become  firmly  adherent  to  the 
lower  portion  of  the  abdominal  parietes,  the  anterior  wall  of  the  uterus  is 
unable  to  expand,  and  the  enlargement  of  the  organ  is  effected  solely  at  the 
expense  of  its  posterior  wall,  the  anterior  wall  forming  a  thick  layer  of 
muscle  which  extends  backward  from  the  point  of  attachment  to  the  cervix. 
Under  such  circumstances  the  latter  is  gradually  drawn  upward  from  its 
usual  position,  until  the  external  os  lies  on  a  level  with  the  promontory  of 
the  sacrum,  and  sometimes  considerably  above  it.  When  labour  sets  in, 
dilatation  of  the  cervix  is  effected  very  imperfectly,  since  the  bag  of  waters 


DYSTOCIA    DTK   TO    VENTROFIXATION   OP   THE    DTERUS  573 

and  the  presenting  part,  instead  of  impinging  upon  it,  are  forced  down 
upon  the  thickened  anterior  wall  of  the  uterus.  Accordingly,  the  uterine 
contractions,  no  matter  how  strong  they  may  be,  are  unable  to  effect  the 
completion  of  labour,  and  unless  suitable  operative  procedures  are  under- 
taken, rapture  of  the  uterus  will  occur,  as  in  one  of  Dickinson's  cases. 

Noble,  in  1896,  collected  the  histories  of  177  cases  of  labour  occurring 
in  women  win)  had  been  subjected  to  ventrofixation,  and  found  that  dys- 
tocia was  frequently  noted.  Csesarean  section  having  been  necessary  four 
times,  not  to  speak  of  numerous  versions  and  other  operations.  Dickinson, 
in  1901,  reported  a  case  of  Csesarean  section  for  the  same  cause,  and  col- 
lected 9  other.-  from  the  literature. 

I  have  delivered  some  20  women  alter  the  performance  of  ventrofixa- 
tion or  suspension  of  the  uterus,  but  in  only  one  was  there  any  serious 
dystocia.  In  this  case  the  patient  was  a  multipara,  who  had  had  several  spon- 
i  aneous  labours  before  the  operation  and  conceived  soon  afterward.  During 
pregnancy  she  complained  of  a  great  deal  of  pain  at  the  lower  end  of  the 
abdominal  incision,  which  was  distinctly  drawn  inward.  Internal  examina- 
tion showed  that  the  cervix  pointed  backward,  the  external  os  being  on  a 
level  with  the  promontory  of  the  sacrum.  After  some  sixteen  hours  of 
strong  labour  pains  the  cervical  canal  was  not  obliterated  and  the  os  meas- 
ured only  2  centimetres  in  diameter,  while  the  head  was  jammed  down  upon 
the  anterior  wall  of  the  uterus.  The  propriety  of  performing  Cesarean 
section  was  considered,  but  it  was  believed  that  the  cervix  could  be  dilated 
manually;  this  was  accomplished  after  considerable  difficulty,  when  version 
was  performed  and  a  living  child  extracted.  The  patient  made  an  unevent- 
ful recovery,  except  that  she  continued  to  complain  of  intense  pain  in  the 
lower  abdomen.  For  this  reason  the  abdomen  was  opened  a  few  weeks 
later,  and  the  fundus  was  found  to  be  firmly  adherent,  having  been  at- 
tached to  the  fascia  and  muscles  of  the  abdominal  wall  by  several  silkworm- 
gut  sutures.    Permanent  relief  followed  the  freeing  of  the  uterus. 

In  view  of  such  experiences,  the  question  arises  whether  the  perform- 
ance  of  ventrofixation  in  women  during  the  childbearing  period  is  a  justi- 
fiable procedure.  My  experience  leads  me  to  believe  that  suspension  of 
the  uterus  is  devoid  of  danger  from  an  obstetrical  point  of  view,  as  in  this 
operation  the  uterus  is  attached  merely  to  the  peritonaeum,  so  that  it  is 
eventually  held  in  place  by  pressure  exerted  by  the  abdominal  contents 
assisted  by  two  newly  formed  peritoneal  ligaments.  If,  however,  it  be  firmly 
sutured  to  the  fascia — a  real  ventrofixation — serious  consequences  may  result 
in  the  next  pregnancy,  and  for  this  reason  the  latter  operation  should  be 
employed  only  in  women  past  the  menopause. 

The  vaginofixation,  suggested  by  Diihrssen  and  Mackenrodt,  in  which 
the  fundus  is  firmly  stitched  to  the  anterior  vaginal  wall,  has  been  followed 
by  such  serious  dystocia  that  it  has  been  practically  abandoned  during  the 
childbearing  period.  Eiihl  has  collected  9  cases  of  Cesarean  section  fol- 
lowing this  operation,  and  Rieck  has  suggested  a  modified  vaginal  Csesarean 
section  for  the  relief  of  the  resulting  dystocia. 

Prolapse. — Pregnancy  cannot  go  on  to  full  term  when  the  uterus  is 
completely  prolapsed,  although  the  size  of  the  uterine  tumour  which  occa- 


574  OBSTETRICS 

sionally  projects  from  the  vulva  may  give  rise  to  a  belief  in  its  possibility^ 
In  such  cases,  however,  careful  examination  will  show  that  the  fundus  oc- 
cupies its  usual  level,  while  the  protrusion  from  the  vulva  is  made  pos- 
sible by  elongation  of  the  lower  uterine  segment  and  hypertrophic  elonga- 
tion of  the  cervix.  As  a  rule,  the  cervix  becomes  retracted  when  labour 
sets  in,  though  in  rare  cases  it  may  continue  to  protrude  from  the  vulva  and 
becomes  markedly  cedematous  and  so  swollen  as  to  give  rise  to  serious  dys- 
tocia. Under  such  circumstances  multiple  incisions  of  the  cervix  may 
be  necessary  in  order  to  effect  delivery. 

Dystocia  Due  to  Tumours  of  the  Generative  Tract  and  Pelvis. — Carci- 
noma of  the  Cervix. — The  effect  of  this  condition  upon  pregnancy  and  labour 
and  its  appropriate  treatment  has  been  considered  in  Chapter  XXVII. 

Fihro-myomata  of  the  Uterus. — Myomata  were  observed  by  Pinard  in  84 
out  of  13,915  consecutive  cases  of  labour — 0.6  per  cent.  It  is  a  matter  of 
general  observation  that  women  suffering  from  this  disease  are  relatively 
sterile.  Thus,  49  of  Pinard's  patients  were  over  thirty  years  of  age  when 
pregnancy  first  occurred. 

The  obstacle  to  conception  is  most  marked  when  the  tumour  is  of  the 
suj2rrmc£U£j3r  interstitial  variety,  and  much  less  so  when  it  is  subserous 
in  origin.  Moreover,  when  pregnancy  occurs,  owing  to  the  hemorrhagic 
changes  in  the  endometrium  which  are  frequently  associated  with  the  pres- 
,  ence  of  submucous  myomata,  there  is  an  increased  tendency  towards  prema- 
\ture  expulsion  of  the  ovum.  On  the  other  hand,  pregnancy  is  not  without 
influence  upon  the  tumojirs  themselves,  which  frequently  irirrpasp  rapidly  in 
size,  more  as  a  result  of  oedema  than  of  actual  hypertrophy.  Moreover,  owing 
to  the  pressure  to  which  they  are  subjected  by  the  growing  ovum,  the  soft- 
ened tumours  undergo  changes  in  shape  and  become  markedly  flattened.  At 
the  same  time  the  pedicles  may  become  twisted  and  gangrene  and  peritonitis 
may  ensue;  while  a  submucous  tumour  may  sometimes  become  loosened 
from  its~b~ed  and  hang  down  into  the  uterine  cavity  or  cervix  as  a  polypus. 

The  diagnosis  of  the  association  of  pregnancy  and  myomata  is  not  always 
easy,  as  haemorrhage  may  occur  at  intervals  as  the  result  of  changes  in  the 
endometrium,  and  be  mistaken  by  the  patient  herself  for  the  menstrual  flow, 
so  that  the  idea  of  pregnancy  may  never  suggest  itself.  On  the  other  hand, 
a  sudden  increase  in  the  rapidity  of  the  growth  of  the  uterine  tumour  should 
direct  attention  to  the  possibility  of  pregnancy,  and  the  diagnosis  becomes 
assured  when  careful  palpation  shows  the  presence  of  soft  areas  interspersed 
between  the  firmer  myomatous  nodules.  Subperitoneal  myomata  occasion- 
ally escape  observation,  being  mistaken  for  small  parts,  or  sometimes  for  the 
head  of  the  foetus,  so  that  a  diagnosis  of  multiple  pregnancy  may  be  made. 

At  the  time  of  labour  the  effect-exerted  by  the  myomata  depends  en- 
tirely upon  their  size  and  situation.  Generally  speaking,  subserous  tumours 
are  without  great  significance,  except  when  their  large  size  leads  to  presr 
sure  symptoms.  On  the  other  hand,  a  pedunculated  tumour  occasionally 
pral apses  into  the  pelvic  cavity  and  gives  rise  to  serious  dystocia.  As  a  rule, 
however,  interstitial  myomata,  developed  in  the  cervix  or  lower  uterine  seg- 
ment, offer  serious  obstacles  to  labour  and  may  so  obstruct  the  pelvic  cavity 
that  normal  delivery  will  be  impossible.     As  a  result  of  the  uterine  con- 


DYSTOCIA   DUE  TO   FIBRO-MYOMATA    OF  THE    UTERUS  57E 

tractions,  submucous  myomata  may  become  partially  separated  from  theii 
bed  and  protrude  from  the  cervix  as  a  polypoid  mass.     Under  such  cir- 
cumstances, since  they  effectively  prevent  the  descent  of  the  bead,  they' 
in nsi  be  removed  by  cutting  through  the  pedicle. 

Even  when  the  tumour  does  not  interfere  with  the  course  of  labour  by 
its  size  and  situation,  ii  frequently  exerts  a  deleterious  influence  upon  the 
position  of  ilic  child.  Thus  Olshausen,  in  tabulating  the  cases  reported  in 
the  Literature,  found  only  53  per  cent  of  vertex  presentations,  as  compared 
with  24  and  l'.»  per cenl  of  breech  and  transverse  presentations  respectively. 
Moreover,  the  mere  presence  of  the  tumour  may  so  interfere  with  the  char- 
acter of  the  uterine  contractions  as  to  cause  dystocia.  In  not  a  few  cases 
the  condition  appears  to  predispose  towards  placenta  praevia,  as  well  as  to 
favour  the  occurrence  of  post-partum  haemorrhage.  The  latter  is  due  partly 
to  the  fact  thai  the  myomatous  nodules  interfere  with  the  normal  contrac-J 
tion  and  retraction  of  the  uterus,  and  partly  because  they  offer  mechanical  J 
obstacles  to  the  separation  and  expulsion  of  the  placenta. 

In  the  puerperium,  myomata  not  infrequently  undergo  degenerative 
changes,  and  if  they  have  been  subjected  to  prolonged  pressure  may  become 
gangrenous.  On  the  other  hand,  in  not  a  few  cases  the  effect  of  pregnancy 
is  beneficent,  as  the  tumours  become  smaller  after  the  birth  of  the  child,  and 
occasionally  disappear  entirely. 

Prognosis. — In  preantiseptic  times  the  outlook  in  labours  complicated 
by  the  presence  of  myomatous  tumours  was  most  serious.  Thus,  the  ma- 
ternal and  foetal  mortality  was  respectively  25  and  79  per  cent  in  307  cases 
collected  from  the  literature  by  Lefour  in  1880.  At  present,  thanks  to  early 
diagnosis  and  prompt  recourse  to  operative  procedures  in  suitable  cases, 
the  prognosis  is  much  more  favourable,  though  at  the  same  time  the  con- 
dition is  sometimes  one  of  the  most  serious  with  which  the  obstetrician  has 
to  cope.  Pinard  reported  that  labour  was  spontaneous  in  54,  and  required 
operative  aid  in  30  of  his  cases,  while  the  maternal  mortality  was  only 
3.6  per  cent. 

Treatment. — When  extreme  distention,  serious  haemorrhage,  or  symp- 
toms of  impaction  occur  before  the  child  has  attained  the  period  of  via- 
bilitv.  laparotomy  is  indicated;  but  whether  removal  of  the  tumour  can  be 
best  effected  by  excision,  enucleation,  supravaginal  or  total  hysterectomy 
will  vary  according  to  circumstances  and  the  predilections  of  the  individual 
operator.  Generally  speaking,  isolated  subserous  myomata  are  best  treated 
by  excision,  and  those  of  the  interstitial  variety  by  enucleation;  whereas, 
if  numerous  tumours  are  present,  supravaginal  hysterectomy  is  indicated 
without  reference  to  the  existence  of  pregnancy. 

Mvomectomy  and  enucleation  are  frequently  followed  by  abortion  or 
miscarriage,  but  do  not  necessarily  destroy  all  chance  of  saving  the  life  of 
the  child.  Notwithstanding  this,  however,  my  own  inclination  is  towards 
supravaginal  amputation,  whenever  operation  is  imperatively  demanded,  as 
being  a  less  dangerous  procedure  as  far  as  the  mother  is  concerned.  Thumin 
has  collected  62  myomectomies,  40  enucleations,  and  98  supravaginal  hys- 
terectomies performed  between  the  years  1885  and  1901,  with  a  mortality 
of  10,  5,  and  11.23  per  cent  respectively. 


576 


OBSTETRICS 


If  serious  symptoms  do  not  supervene  during  pregnancy,  the  patient 
should  be  examined  thoroughly  under  anaesthesia  shortly  before  the  ex- 
pected date  of  confinement.  If  the  tumour  is  found  to  be  firmly  impacted 
in  the  pelvis,  Caesarean  section  should  be  performed  before  labour  sets  in, 
followed  by  supravaginal  amputation  or  complete  hysterectomy,  according 
to  the  judgment  of  the  operator.  On  the  other  hand,  if  there  is  appar- 
ently no  danger  of  impaction,  and  spontaneous  delivery  is  probable,  the 
patient  may  be  allowed  to  go  into  labour.  But  if  symptoms  of  obstruction 
occur,  Caesarean  section  should  be  promptly  performed  in  preference  to  at- 
tempts at  delivery  by  the  more  usual  obstetrical  procedures. 

Ovarian  Tumours. — The  presence  of  an  ovarian  tumour  is  one  of  the 
most  serious  complications   of  pregnancy,   as   it   markedly  increases  the 


Fig.  483. — Dystocia  Due  to  Ovarian  Cyst  (Bumm). 


probability  of  abortion  and  frequently  offers  an  insuperable  obstacle  to 
delivery  at  the  time  of  labour.  Moreover,  even  after  a  spontaneous  labour, 
its  presence  occasionally  gives  rise  to  disturbances  during  the  puerperium. 

While  any  variety  of  ovarian  tumour  may  complicate  pregnancy  and 
labour,  dermoid  cysts  have  been  described  comparatively  frequently  in  this 
connection.  Thus,  in  107  cases  collected  by  McKerron,  in  which  the 
nature  of  the  tumour  was  stated,  there  were  47  cystomata,  46  dermoid  cysts,. 
9  malignant  tumours,  5  fibromata,  and  2  colloid  cysts.  Swan,  in  1898,  was 
able  to  collect  14  cases  of  solid  ovarian  tumours. 

Of  the  321  pregnancies  complicated  by  ovarian  tumours  collected  by 
Eemy,  spontaneous  abortion  or  premature  labour  occurred  in  17  per  cent- 


DYSTOCIA    DUE   TO   OVARIAN   TUMOURS  bli 

If  the  tumour  occupies  the  pelvic  cavity  it  may  give  rise  to  most  serious 
dystocia.  Thus,  McKerron,  in  183  cases  collected  from  the  literature,  noted 
a  maternal  mortality  of  30.5  per  cent,  while  more  than  half  of  the  chil- 
dren were  Lost.  The  majority  of  these  cases,  however,  were  reported  prior 
to  the  introduction  of  more  radical  surgical  methods,  very  few  Laparotomies 
having  been  performed,  and  interference  for  the  most  part  being  limited  to 
puncture  or  incision  of  cysts  through  the  vagina.  Moreover,  the  danger 
to  the  patient  does  not  end  with  the  birth  of  the  child,  as  in  not  a  few 
cases  peritonitis  follows  gangrene  of  the  tumour  resulting  from  excessive 
pressure,  while  in  others  torsion  of  the  pedicle  may  lead  to  a  fatal  ter- 
mination. 

Again,  the  cyst  may  rupture  and  extrude  its  content-  into  the  peritoneal 
cavity  during  a  spontaneous  labour  or  as  the  result  of  operative  interference. 
This  event  is  a  matter  of  indifference  with  the  ordinary  cystomata,  but  in 
the  case  of  a  dermoid  cyst  is  frequently  followed  by  fatal  peritonitis.  In 
other  instances  rupture  of  the  uterus  occurs,  or  the  tumour  is  forced  into 
the  vagina  and  occasionally  even  into  the  rectum. 

Diagnosis. — Unfortunately,  the  presence  of  an  ovarian  tumour  com- 
plicating pregnancy  often  remains  unrecognised,  the  condition  having 
escaped  observation  in  all  but  18  of  McKerron's  cases.  Xevertheless,  more 
careful  observation  would  certainly  eliminate  a  large  proportion  of  these 
errors.  Any  excessive  enlargement  of  the  abdomen  or  the  appearance  of 
pressure  symptoms  should  always  lead  one  to  make  a  careful  examination, 
and  in  not  a  few  cases  a  tumour  will  be  found  occupying  the  pelvic  cavity. 
Again,  failure  of  the  presenting  part  to  engage,  when  the  pelvis  is  known  to 
be  normal,  suggests  an  obstructing  mass.  On  the  other  hand,  if  the  tumour 
does  not  occupy  the  pelvic  cavity,  the  diagnosis  is  extremely  difficult,  and 
the  abdominal  enlargement  is  frequently  attributed  to  the  presence  of  twin 
pregnancy  or  hydramnios,  and  the  true  condition  is  not  recognised  until 
after  labour. 

Treatment. — If  the  tumour  is  detected  prior  to  the  last  month  of  preg- 
nancy, it  should  be  removed  at  once  by  laparotomy.  Orgler  has  collected 
142  such  operations,  with  a  maternal  mortality  of  2 .  T  T  per  cent. 

It  has  been  objected  that  such  a  procedure  increases  the  chances  of 
premature  delivery,  which  occurred  in  22.5  per  cent  of  Orglers  cases.  It 
should,  however,  be  remembered  that  a  similar  accident  may  take  place 
even  if  the  patient  is  not  interfered  with,  being  noted  in  1?  per  cent  of 
Remy's  cases.  This  difference  is  so  slight  that  the  chances  for  the  child 
are  little,  if  at  all.  impaired  by  operation,  while  those  of  the  mother  are 
markedly  improved. 

On  the  other  hand,  when  the  diagnosis  is  not  made  until  the  last  month 
of  pregnancy,  it  is  usually  advisable  to  postpone  the  operation  until  term. 
for  the  reason  that  the  fresh  abdominal  cicatrix  is  not  well  adapted  to  the 
strain  of  parturition.  At  the  time  of  labour,  if  the  tumour  is  impacted  in 
the  pelvis,  unanimous  opinion  favours  its  immediate  removal  by  laparotomy. 
Bland  Sutton  and  most  authorities  advise  that  the  abdomen  should  then  be 
closed  and  the  birth  of  the  child  left  to  Nature,  or  at  most  assisted  by 
forceps.    On  the  other  hand,  Hirst  is  strongly  of  the  opinion  that  a  supple- 


578  OBSTETRICS 

mentary  Cesarean  section  should  immediately  follow,  believing  that  the 
woman  should  not  he  submitted  to  the  strain  of  labour  immediately  after  a 
severe  operation,  and,  when  all  things  are  considered,  the  latter  appears 
to  me  to  be  the  wiser  course. 

Formerly  it  was  advised  to  attempt  the  reposition  of  the  mass  under 
anaesthesia.  This  practice,  however,  is  not  to  be  recommended,  for  the 
reason  that  the  tumour  is  very  liable  to  give  rise  to  trouble  during  the 
puerperium.  Moreover,  since  operative  interference  will  be  necessary  sooner 
or  later,  it  would  seem  far  better  to  institute  radical  measures  without  delay. 
Puncture  through  the  vagina,  although  strongly  advocated  at  one  time, 
must  be  considered  as  a  dangerous  and  extremely  reprehensible  practice, 
inasmuch  as  we  possess  no  means  of  preventing  the  tumour  contents  from 
contaminating  the  peritoneal  cavity. 

If  spontaneous  labour  has  occurred,  the  patient  should  be  carefully 
watched  during  the  puerperium  for  the  appearance  of  untoward  symptoms. 
Should  they  arise,  prompt  operation  is  imperatively  demanded.-  In  any 
event,  a  woman  suffering  from  an  ovarian  tumour  should  not  be  discharged 
from  treatment  until  the  tumour  has  been  removed,  or  at  least  until  the 
importance  of  operative  procedures  have  been  strongly  urged  upon  her. 

Tumours  of  Other  Origin. — Labour  is  occasionally  obstructed  by  tumours 
of  various  origin,  which  encroach  upon  the  cavity  of  the  pelvis  to  such 
an  extent  as  to  render  delivery  difficult  or  even  impossible.  In  Chapter 
XXXVIII  reference  will  be  made  to  dystocia  due  to  tumours  arising  from 
the  pelvic  walls. 

In  rare  instances  a  normal  sized  or  enlarged  kidney  or  spleen  may  pro- 
lapse into  the  pelvic  cavity  and  offer  an  obstacle  to  labour.  Bland-Sutton 
has. added  an  additional  case  of  displaced  kidney  complicating  pregnancy 
to  those  collected  by  Cragin;  he  has  also  reported  the  removal  of  a  prolapsed 
spleen  in  the  second  month  of  pregnancy,  which  would  have  given  rise  to 
serious  dystocia  at  the  time  of  labour  had  it  remained  in  situ. 

Echinococcus  cysts  are  occasionally  implanted  in  the  pelvic  cavity. 
Franta,  in  1902,- collected  22  cases  noted  during  pregnancy  and  discussed 
their  effect  upon  the  course  of  labour. 

In  Chapter  XXX  reference  was  made  to  those  cases  in  which  an  old 
extra-uterine  gestation  sac  so  obstructed  the  pelvic  canal  as  to  interfere 
with  the  delivery  of  a  subsequent  intra-uterine  pregnancy. 

Enterocele  or  hernia  through  the  vaginal  walls  occasionally  gives  rise  to 
dystocia,  though  in  the  majority  of  cases  the  prolapsed  intestine  can  be 
replaced  and  the  obstacle  temporarily  overcome.  Where  this  is  not  pos- 
sible, Csesarean  section  is  indicated  as  a  more  conservative  procedure  than 
forcibly  dragging  the  child  over  a  large  irreducible  hernia. 

In  occasional  instances  tumours  of  the  bladder  or  large  vesical  calculi  may 
likewise  offer  an  impediment  to  the  passage  of  the  child,  though  it  is  rarely 
so  serious  as  to  demand  operative  interference.  On  the  other  hand,  cases 
have  been  reported  in  which  it  has  been  necessary  to  remove  a  large  calcu- 
lus from  the  bladder  before  delivery  could  be  effected. 

A  large  rectocele  or  cystocele,  though  occasionally  offering  an  obstacle  to 
labour,  can  generally  be  replaced  while  delivery  is  being  effected. 


DYSTOCIA   DUE  TO  ABNORMALITIES  OF  THE  GENERATIVE  TRACT    579 

Tumours  arising  from  the  lower  pari  of  the  rectum  or  pelvic  connective 
tissue  may  likewise  give  rise  to  serious  dystocia,  Holzapfel  having  collected 
the  cases  in  which  carcinoma  of  the  rectum  rendered  Cesarean  section 
necessary. 

LITERATURE 

Bland-Sutton.    The  Surgery  of    Pregnancy  and   Labour  complicated   with   Tumours. 

Lancet,  L901,  i.  382-386 ;  452-456;  529-532. 
Brindeau,     De  I'atresie  acquise  du  vagin  au  point  do  vue  obstetricale.     L'Obstetrique, 

L901,  \i.  97-122. 
Coester.     Qeber  Geburtshindernisse  durch  hymenale  Balken,  etc.     I).  I.,  Marburg,  1900. 
Cragin.     Congenita]    Pelvic   Kidney  obstructing  the   Parturient  Canal.     Amer.  Jour. 

Obst.,  L898,  xxxviii.  36-41. 
Davet,     I>e  la  dystocie  due  a  la  contracture  du  muscle  releveur  de  l'anus.    These  de 

Paris.  1900. 
Dickinson.     Pregnancy   following  Ventrofixation.     Amer.  Jour.  Obst.,  1001,  xliv,  34-45. 
Fkaxta.     Les  kystes  hydatiquesdu  bassin  et  de  Pabdomen  au  point  de  vue  de  la  dystocie. 

Annales  de  gyn.  et  d'obst,  1002,  lvii.  165-107;  206-308. 
GrUDER.     Ueber  Geschwiilste  der  Vagina  als  Schwangerschaft  und  Geburtskomplikationen. 

D.  I.,  Bern,  1889. 
Hirst.     Ovarian  Cysts.     A  Text-Book  of  Obstetrics.     Third  edition,  1001,  515-517. 
Holzapfel.     Kaiserschnitt  bei  Mastdarmkrebs.     Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1800, 

ii,  50-77. 
Le  Bigot.     De  Pinfluences  du  chancre  syphilitique  de  col  de  l'uterus  sur  Paceouchement. 

These  de  Paris,  1890. 
Lefol'r.     Quoted  by  Olshausen. 
McKerron.     The  Obstruction  of  Labour  by  Ovarian  Tumours  in  the  Pelvis.     Trans. 

Loud.  Obst.  Soc,  1897,  xxxix,  334-382. 
vox  Meer.     Conception  und  Abort  durch  den  Ausfiihrungsgang  der  Blase  bei  angebor- 

ener  Defect  der  Vagina.     Hegar's  Beitrage  zur  Geb.  u.  Gyn.,  1900,  iii,  400-424. 
Neugebauer.     Zur  Lehre  von  den   angeborenen  und  erworbenen  Verwachsungen  und 

Verengerungen  der  Scheide.     Berlin,  1895. 
Xoble.     Suspensio  Uteri  with  Reference  to  its  Influence  upon  Pregnancy  and  Labour. 

Trans.  Amer.  Gyn.  Soc,  1806,  xxi,  247-268. 
<»ldham.     Sacculation  of  the  Uterus.     A  Case  of  Retroflexion  of  the  Gravid  Uterus. 

Trans.  Lond.  Obst,  Soc,  1860,  i,  317-322. 
Olshausen.      Myoni  und  Schwangerschaft.     Veit's  Handbuch  der  Gyn.,  1807,  ii,  765-814. 
Orgler.     Zur  Prognose  und  Indikation  der  Ovariotomie  wiihrend  der  Schwangerschaft. 

Arch.  f.  Gyn.,  1001.  lxv,  126-160. 
Pixard.     Fibromes  et  grossesse.     Annales  de  gyn.  et  d'obst.,  1001,  lv,  165-167. 
Remy.     De  la  grossesse  compliquee  de  kyste  ovarique.     Paris,  1886. 
RrECK.     Vaginifixur  und  Geburt.     Monatsschr.  f.  Geb.  u.  Gyn.,  1001,  xiv,  237-254. 
Ruhl.     Kritische  Bemei-kungen  uber  Gebnrtsstorungen  nach  Vaginalfixatio-uteri.     Mo- 

natsschr.  f.  Geb.  u.  Gyn.,  1901,  xiv.  477-011. 
Schexk.     Hochgradige  frische  Aetzstenose  der  Cervix  und  des  Fornix  in  der  Schwanger- 
schaft.    Centralbl.  f.  Gyn.,  1000,  161-170. 
Schroeder.     Conglutinatio  orificii  extend.     Lehrbuch  der  Geburtsh.,  XIII.  Aufl.,  1800, 

590-592. 
Swax.     The  Management  of  Solid  Tumours  of  the  Ovaries  complicating  Pregnancy,  with 

Report  of  a  Successful  Case.     Bull.  Johns  Hopkins  Hosp.,  1898,  ix,  56-61. 
Thl'MIX.     Chirurgische  Eingriffe  bei  Myomen  der  Gebarmutter  in  Schwangerschaft  und 

Geburt.     Archiv  f.  Gyn.,  1001,  lxiv,  457-525. 
Ward.     Atresia  Vagina?  complicating  Labour.     Obstetrics,  1800,  i,  623-625. 
38 


CHAPTEE    XXXIII 

CONTRACTED  PELVIS— HISTORY,   FREQUENCY,   METHODS  OF 
DIAGNOSIS,   AND   CLASSIFICATION 

We  consider  a  pelvis  contracted  when  it  is  shortened  to  such  an  extent 
in  one  or  more  of  its  diameters  as  to  affect  materially  the  mechanism  of 
labour,  but  without  necessarily  retarding  the  birth  of  the  child.  According 
to  Litzmann  this  is  the  case  when  the  conjugata  vera  measures  9.5  centime- 
tres or  less  in  flat,  and  10  centimetres  or  less  in  generally  contracted  pelves. 

History. — Inasmuch  as  Vesalms  was  the  first  to  describe  the  normal 
pelvis  correctly,  it  is  clear  that  the  conception  of  contracted  pelves  could 
not  have  existed  before  his  time.  His  pupil,  J.  C.  Arantius  (1ji30zl89), 
gave  the  first  anatomical  description  of  an  abnormal  pelvis,  but  his  discov- 
ery exerted  no  appreciable  effect  upon  the  obstetrical  art  of  the  period,  for 
the  reason  that  Ambroise  Pare  still  held  to  the  old  view  of  the  separation 
of  the  pubic  bones  during  labour,  and  promulgated  it  in  his  writings. 

During  the  next  century  knowledge  of  the  subject  advanced  but  slowly, 
and  we  find  Mauriceau  (1637-1709)  stating  that  in  his  very  large  experience 
he  had  observed"  only  two  instances  of  contracted  pelvis.  In  one  of  these 
Chamberlen  was  permitted  to  apply  the  forceps  invented  by  his  uncle,  but 
failed  to  effect  a  delivery.  ^ 

We  are  indebted  to  Heinrich  van  Deyenter  for  our  first  knowledge  of 
contracted  pelves  from  an  obstetrical  standpoint.  In  his  Xew  Light  for 
Midwives,  which  appeared  in  1701,  he  described  the  two  most  usual  varie- 
ties of  contracted  pelvis — the  generally  contracted  and  the  flat — and  dis- 
cussed the  influence  which  they  exerted  upon  labour.  From  that  time  on 
mention  of  the  subject  is  to  be  found  in  all  the  text-books,  De  la  Motte, 
Puzos,  and  Dionis  being  the  obstetricians  of  the  first  half  of  the  eighteenth 
century  who  devoted  most  attention  to  it.  The  last-named  observer  was 
the  first  to  point  out  the  causal  relation  which  rhachitis  bears  to  many  cases 
of  pelvic  deformity. 

Most  important  contributions  to  the  subject  were  made  by  Smellie.  In 
his  treatise  on  The  Theory  and  Practice  of  Midwifery,  published 'in  1752, 
is  to  be  found  an  excellent  description  of  the  normal  pelvis,  as  well  as  of  the 
most  usual  varieties  of  deformity  to  which  it  is  subject.  He  also  laid  down 
practical  rules  for  the  estimation  of  the  degree  of  contraction,  carefully 
described  the  mechanism  of  labour  in  such  cases,  and  gave  excellent  pictures 
showing  the  influence  exerted  by  the  contracted  pelvis  upon  the  foetal  head. 

Baudelocque  (1746-1810)  contributed  largely  towards  the  development 
'  580      ' 


FREQUENCY  OF  CONTRACTED  PELVES  58] 

of  <>ur  knowledge  of  the  subject,  as  he  devoted  particular  attention  to  the 
diagnosis  of  the  condition  in  the  living  woman,  and  showed  that  it  could 
be  detected  by  measuring  the  distance  between  certain  external  bony  parts 
of  the  pelvis  by  mean-  of  a  pair  of  calipers.  He  was  the  first  to  describe 
the  external  conjugate,  which  is  now  generally  known  by  his  name,  and 
taught  that  the  length  of  the  conjugata  vera  could  be  readily  and  accu- 
rately estimated  by  deducting  3  inches  from  it. 

At  the  same  time  <■.  W.  Stein,  in  Germany,  did  good  work  upon  some- 
what similar  lines  and  devised  a  pelvimeter  for  the  direct  mensuration  of 
the  conjugata  vera. 

The  real  foundation,  however,  for  the  modern  doctrine  concerning 
contracted  pelves  was  laid  by  Miehealis  and  Litzmann.  The  former  was 
Professor  of  Obstetrics  in  the  University  of  Kiel  from  18-13  to  1850,  and 
during  that  time  carefully  measured  the  pelvis  in  1,000  consecutive  cases 
of  lahour.  He  designated  as  contracted  all  pelves  in  which  the  conjugata 
vera  measured  8.75  centimetres  or  less,  and  found  72  such  cases  in  his 
series,  a  percentage  of  7.2.  After  his  death  he  was  succeeded  by  Litzmann, 
who  continued  the  work,  and  soon  reported  accurate  measurements  based 
upon  a  second  series  of  1,000  cases.  He  advanced  the  definition  which  was 
given  at  the  beginning  of  the  present  chapter,  and  considered  as  con- 
tracted all  pelves  having  a  conjugata  vera  of  10  or  9.5  centimetres  or 
less,  according  as  they  were  generally  contracted  or  flat,  respectively. 
Judged  by  these  criteria  he  found  that  11.9  per  cent  of  his  pelves  were 
abnormal,  and  estimated  that  had  Michealis  employed  the  same  standard 
his  percentage  would  have  been  13.1. 

Litzmann's  definition  and  criteria  have  been  adopted  throughout  the 
world,  and  since  the  appearance  of  his  work  scientific  obstetricians  have  de- 
voted a  considerable  amount  of  attention  to  the  subject.  To  mention  all  who 
have  added  materially  to  our  knowledge  would  be  equivalent  to  writing  the 
history  of  obstetrics  for  the  past  fifty  years;  but  Xaegele, Kilian,  Schauta, and 
Breus  and  Kolisko  may  be  cited  as  among  the  most  important  contributors. 

Frequency. — In  this  country  and  in  England  very  few  statistics  are 
available  upon  which  to  base  accurate  statements  as  to  the  frequency  of 
contracted  pelves,  but  in  Germany  and  France  many  of  the  large  lying-in 
hospitals  supply  valuable  data.  The  frequency  of  pelvic  deformity  varies 
considerably  in  different  countries,  and  even  in  various  parts  of  the  same 
country.  Thus,  as  is  shown  by  the  following  table,  a  frequency  ranging 
from  J>  to  21  per  cent  is  reported  from  the  various  German  clinics. 

Goenner  f  Basel) observed       7.9    per  cent  in  2.433  cases. 

Glaser  (Wtirzburg). " 

Heinsius  (Breslau) " 

Prune!  (Munich) 

Fuchs  (Erlaneen) " 

Miehealis  (Kiel) " 

Kottgen  (Bonn) "■ 

Litzmann  (Kiel) " 

Miiller  (Berne) " 

Weidenmuller  (Marburg) ...  " 

Leopold  (Dresden) " 


8.4 

••  1.812      ' 

8.5 

••  1.641      ' 

9.5 

•;  1.199     ' 

11.43       " 

•■  1.766      ' 

13.1 

•;  1.000     ' 

13.45       " 

-  2.000     • 

14.9 

••  1.000     ' 

16 

■;  1.177      ■ 

18.7 

"  3,224      ' 

24.3          " 

•'  2.415      ' 

582  OBSTETKICS 

Winckel  states  that  contracted  pelves  are  observed  in  from  10  to  15 
per  cent  of  all  German  women,  while  Schauta  estimates  that  the  condition 
is  met  with  in  one  Avoman  out  of  seven.  The  statistics  from  the  Austrian 
Empire  seem  to  indicate  a  lesser  frequency  than  in  Germany,  as  is  shown 
by  the  following  table: 

Knapp  (Prague) observed  2.44  per  cent  in    4,289  cases. 

Ludwig  and  Savor  (Vienna)..  "        3.84       "         "    50,621      " 

Pawlik  (Prague) "        7.8         "         "   29,615     " 

Large  series  of  statistics  are  not  available  for  France.  The  yearly 
reports  from  Pinard's  clinic,  however,  indicate  a  frequency  of  about  5  per 
cent,  while  Budin  gives  8  per  cent  in  7,687  cases,  and  Tarnier  16  per  cent 
in  715  cases. 

Fancourt  Barnes,  in  1897,  reported  that  only  0.5  per  cent  of  contracted 
pelves  were  observed  in  38,065  cases  of  labour  in  London.  In  view  of  the 
fact,  however,  that  every  year  a  considerable  number  of  Cassarean  sections 
are  performed  in  that  city  for  this  indication,  it  would  appear  probable  that 
his  figures  in  no  way  represent  the  true  condition. 

It  has  been  a  matter  of  general  belief  that  in  this  country  contracted 
pelves  are  very  rare,  and  Dewees  stated  in  1824  that  he  had  observed  only 
three  cases  in  his  large  experience.  Lusk  held  a  similar  opinion,  and  said 
that  rhachitis  is  rarely,  and  osteomalacia  never,  observed  among  native 
American  women.  Hirst,  on  the  other  hand,  states  that  these  diseases  are 
not  of  infrequent  occurrence,  and  that  no  one  who  practises  obstetrics  can 
fail  to  meet  with  occasional  examples. 

We  owe  to  Reynolds  the  first  statistical  statement  upon  the  subject  in 
this  country.  In  1890  he  reported  that  he  had  observed  1.3-1  per  cent  of 
contracted  pelves  in  2,227  women  delivered  in  Boston.  His  statements, 
however,  must  be  accepted  with  reserve  and  as  underestimating  the  fre- 
quency of  the  condition,  since  he  measured  the  pelvis  only  in  those  cases 
which  required  operative  interference,  and  left  out  of  consideration  those 
in  which  labour  terminated  spontaneously.  Had  he  taken  these  into  ac- 
count he  would,  in  all  probability,  have  reported  a  frequency  of  6.8  per  cent. 
Flint  observed  1.42  per  cent  of  contracted  pelves  in  10,233  consecutive  cases 
delivered  in  ISFew  York;  but  his  figures  cannot  be  considered  to  represent 
the  frequency  of  the  condition  in  this  country,  as  his  material  was  com- 
posed almost  entirely  of  Polish  and  Russian  Jewesses,  only  9  per  cent  of 
his  patients  being  native-born  Americans. 

Crossen,  of  St.  Louis,  reports  a  frequency  of  8  per  cent,  and  Davis  states 
that  there  were  25  per  cent  of  contracted  pelves  in  1,224  cases  delivered 
under  his  supervision  in  Philadelphia.  The  latter's  estimates,  however, 
were  based  almost  entirely  upon  external  pelvic  mensuration,  which,  as 
will  be  pointed  out  later,  gives  an  exaggerated  idea  of  the  frequency  of  the 
condition.  . _,_    - 

Since  the  opening  of  the  lying-in  department  of  the  Johns  Hopkins 
Hospital,  it  has  been  our  rule  to  measure  both  externally  and  internally 
the  pelvis  of  every  pregnant  woman  who  comes  into  our  hands.  In  1899  I 
reported  that  we  had  met  with  131  contracted  pelves  in  the  first  1,000 


METHODS  OF  DETECTING   CONTRACTED   PELVES  583 

women  delivered.  En  June,  L901,  I  gave  the  results  obtained  in  L,123  addi- 
tional cases,  which  show  I'd  exactly  the  same  percentage  as  in  the  previous 
report.    Thus,  a  total  of  2,133  cases  gave  a  percentage  of  L3.1. 

One  reason  for  the  marked  frequency  of  contracted  pelves  in  Balti- 
more is  probably  due  to  the  faci  thai  mure  than  half  of  our  patients  are 
coloured,  941  in  the  entire  series  being  while  and  1,182  black  women.  Jn 
the  former  we  found JjJ^juid  in  the  latter jLSjjffjJer  cent  of  contracted 
pelves.  In  other  words,  about  every  fourteenth  white  and  every  fifth 
coloured  woman  of  the  poorer  classes  in  Baltimore  has  an  abnormal  pelvis. 
From  the  statistics  of  Reynolds.  Crossen,  and  my  own — derived  from  Bos- 
ton, .St.  Louis,  and  Baltimore  respectively — it  would  appear  that  contracted 
pelves  occur  in  from  7  to  8  per  cent  of  the  white  women  of  this  country. 
Hence,  it  will  be  evident  that  no  one  can  practise  obstetrics  without  en- 
countering a  certain  number  of  such  cases. 

Methods  of  Diagnosis. — It  is  essential  that  the  obstetrician  be  able  to 
diagnose  the  existence  and  extent  of  the  condition  before  the  onset  of 
labour,  in  order  that  he  may,  as  far  as  possible,  decide  in  advance  upon  the 
proper  line  of  treatment  to  be  instituted  in  each  case.  With  this  object 
in  view  accurate  pelvic  mensuration  should  constitute  an  integral  part  of 
the  preliminary  examination  of  pregnant  women,  and,  in  the  present  state 
of  our  knowledge,  a  physician  who  practices  obstetrics  without  pelvimetry 
must  be  regarded  as  no  better  than  one  who  treats  diseases  of  the  heart 
and  lungs  without  the  aid  of  auscultation  and  percussion. 

At  the  preliminary  examination,  which  should  be  made  four  to  six 
weeks  before  the  expected  time  of  confinement,  the  physician  should 
neglect  no  means  of  obtaining  all  possible  data  bearing  upon  the  case. 
Generally  speaking,  large_,  well-built  women  are  likely  to  have  normal,  and 
undersized  women  contracted  pelves;  but  this  rule  by  no  means  always 
holds  good,  and  it  is  not  unusual  for  examination  to  disclose  some  abnor- 
mality in  the  former  and  perfectly  normal  pelves  in  the  latter. 

The  gait  of  the  patient  should  be  carefully  noted,  since  the  existence  of 
a  limp  or  some  peculiar  way  in  which  the  feet  are  placed  upon  the  floor 
may  serve  to  direct  attention  to  the  possibility  of  a  pelvic  deformity. 
ITarked  abnormalities  of  the  spinal  column — kyphosis  or  lordosis — are  also 
suggestive,  and  even  slight  degrees  of  spinal  curvature  should  not  be  over- 
looked, as  they  are  not  infrequently  of  rhachitic  origin.  The  more  usual 
signs  of  rhachitis — deformities  of  the  extremities,  the  characteristically 
shaped  head,  and  the  rhachitic  rosary — should  also  be  looked  for.  Inquiry 
should  always  be  made~as  to  the  age~at  which  the  patient  first  learned  to 
walk,  and  if  she  is  found  to  have  been  backward  in  this  respect  the  possi- 
bility  of  a  rhachitic  pelvis  should  be  borne  in  mind,  even  though  the  usual 
external  manifestations  of  the  disease  may  be  lacking. 

If  the  patient  has  already  borne  children  she  should  be  questioned 
as  to  the  course  of  previous  labours,  and  the  history  of  any  serious  diffi- 
culty should  always  suggest  the  possibility  of  an  abnormal  pelvis.  On  the 
other  hand,  a  negative  history  is  by  no  means  so  valuable,  as  it  is  a  well- 
known  fact  that  in  moderate  degrees  of  pelvic  contraction  the  first  labour 
may  be  relatively  easy,  while  each  successive  one  becomes  more  difficult. 


584 


OBSTETRICS 


Fig.  484. — Budin's 
Pelvimeter. 


Fig.  485.— Martin's 
Pelvimeter. 


In  primiparous  women  a  markedly  pendulous  abdomen  should  always  be 
regarded  as  evidence  of  the  existence  of  a  marked  disproportion  between 

the  child's  head  and  the  pelvis  until 
careful  examination  shows  that  such 
is  not  the  case. 

Pelvimetry. — While  the  above- 
mentioned  conditions  are  of  value 
in  suggesting  the  possibility  of  pel- 
vic deformit}r,  accurate  information 
as  to  its  existence  and  extent  can 
be  obtained  only  by  measuring  the 
pelvis. 

For  this  purpose  external  or  in- 
ternal pelvimetry  may  be  employed, 
according  as  the  measurements  are 
taken  from  the  surface  of  the  body 
or  through  the  vagina.  As  has  al- 
ready been  said,  Baudelocque  was 
the  first  to  insist  upon  the  impor- 
tance and  value  of  the  former,  and 
invented  the  first  pelvimeter,  which 
consisted  of  a  pair  of  calipers  or 
compasses  provided  with  a  scale  to 
indicate  the  extent  to  which  they 
are  opened.  Innumerable  instru- 
ments of  this  kind  have  since  been  devised,  but,  although  most  of  them 
give  satisfactory  results,  before  buying  one  it  is  always  well  to  see  that  the 
blades  are  sufficiently  curved  to  allow  them  to  span  the  thighs  of  stout 
patients.  Thus,  Budin's  pelvimeter  (Fig.  484),  which  can  readily  be  carried 
in  the  pocket,  gives  satisfactory  results  in  the  vast  majority  of  cases:  but 
it  cannot  be  used  to  measure 
the  external  conjugate  in  stout 
women,  owing  to  the  slight 
curvature  of  its  blades.  Per- 
sonally, I  usually  employ  the 
instrument  devised  by  E.  Mar- 
tin (Fig.  485). 

In  external  pelvimetry  the 
ordinary  measurements  are 
four  in  number.  Thus  we  as- 
certain accurately  the  distance 
between  the  anterior  superior 
spines  of  the  ilium,  between 
the  external  edges  of  the  crests 
of  the  ilium,  between  the 
heads  of  the  trochanters,  and 
between  the  spinous  process  of  the  last  lumbar  vertebra  and  the  anterior 
surface  of  the  symphysis  pubis.    Normally  these  measure  26,  29,  32,  and  21 


Fig.  486. — Method  of  holding  Pelvimeter. 


EXTERNAL    PELVIMETRY 


:,s5 


centimetres  respectively.     Naegele  suggested  certain  other  measurements, 

which  as  a  rule,  however,  are  o.o1  employed  unless  one  suspects  the  exist- 
ence of  an  obliquely  contracted  pelvis. 

When  the  pelvis  is  to  be  measured  externally,  the  patient  should  lie 
upon  a  bed  or  table  with  tier  abdomen  and  hips  either  bared  or  covered 
only  by  a  thin  chemise.  The  legs  and  upper  portions  of  the  hody  should 
not  be  exposed.  The  physician,  sitting  on  the  side  of  the  bed  facing  the 
patient,  grasps  the  tips  of  the  pelvimeter  between  the  thumb  and  second 
linger  of  each  hand,  the  index  lingers  being  left  free.  With  the  latter  he 
Locates  the  outer  edges  of  the  anterior  superior  spines,  and  with  the  other 


Fig.  487. — Measuring  the  Distance  between  the  Anterior  Superior  Spines. 


fingers  presses  the  tips  of  the  pelvimeter  upon  them  as  closely  as  possible, 
the  distance  between  them  being  indicated  on  the  scale  of  the  instrument. 
In  measuring  the  distance  between  the  iliac  crests,  the  most  widely  sepa- 
rated portions  are  located,  and  the  tips  of  the  pelvimeter  applied  to  their 
outer  edges.  In  taking  these  measurements,  it  should  be  borne  in  mind 
that  the  iliac  spines  and  crests  present  an  outer  and  inner  lip  and  an  interme- 
diate ridge,  and  that  the  distance  between  the  outer  lips  of  the  spines  and 
crests  is  1.5  to  2.5  centimetres  greater  than  that  between  the  inner  lips. 


586 


OBSTETRICS 


In  determining  the  distance  between  the  trochanters,  the  patient's  legs 
having  been  brought  into  close  apposition;  the  examiner  carefully  palpates 
the  upper  portion  of  the  thighs  until  the  most  prominent  points  of  the 
trochanters  are  felt  on  either  side.     The  tips  of  the  pelvimeter  are  then 


Fig.  488. — Measuring  the  External  Conjugate. 


firmly  pressed  against  them,  so  that  they  come  into  closest  possible  con- 
tact with  the  bones,  after  which  the  measurement  is  read  off  on  the  scale. 
The  external  conjugate,  or  Baudelocque's  diameter,  extends  from  a  de- 
pression just  beneath  the  spine  of  the  last  lumbar  vertebra  to  the  anterior 
and  upper  margin  of  the  symphysis  pubis.  For  this  measurement,  the 
woman  should  lie  on  her  side  with  her  back  towards  the  physician.  As 
a  rule  the  spine  of  the  last  lumbar  vertebra  is  readily  found  by  palpating 
the  spinous  processes  from  above  downward,  the  last  and  most  prominent 
being  usually  that  of  the  last  lumbar  vertebra.  Immediately  beneath  it 
is  a  slight  depression,  which  forms  the  posterior  extremity  of  the  diameter 
to  be  measured.  Into  this  one  tip  of  the  pelvimeter  should  be  inserted  and 
held  firmly  in  place,  while  the  other  hand  seeks  the  upper  margin  of  the 
symphysis  pubis,  andTTrmly  applies  the  other  tip  of~f"hlT  pelvimeter  to  it. 
The  distance  separating  them  is  then  read  off  on  the  scale. 


EXTERNAL    PELVIMETRY 


587 


N*   9 


In  stout  women  considerable  difficulty  may  be  experienced  in  locating 
the  posterior  extremity  of  the  diameter,  owing-  to  the  fact  that  the  spinous 
process  of  the  last  Lumbar  vertebra  cannot  he  identified.  This  difficulty 
can  usually  lie  obviated  in  the  following  manner:  A  line  is  drawn  betweeD 
the  depressions  marking  the  attachment  of  the  fascia  to  the  superior  pos- 
terior spines  of  the  ilium,  and  which  are  usually  clearly  visible.  A  point 
3.5  centimetres  above  the  middle  of  this  line  will  usually  correspond  to  the 
point  required,  and  will  lie  at  the  apex  of  a  rhomboidal  figure — Michealis's 
rhomboid — whose  upper  and  lower  margins  are  formed  by  the  transverse 
and  sacro-spinalis  and  gluteus  muscles  respectively. 

Tin'  V '<il 'in1  of  External  Pelvimetry. — As  was  said  above,  the  external 
conjugate  was  first  described  by  Baudelocque,  who  stated  that  by  deduct- 
ing 3  inches  from  it  the  length  of  the  true  conjugate  could  be  accurately 
est  i  mated.  He  based  his  opinion  upon  the  fact  that 
he  had  rarely  observed  a  difference  of  more  than  1 
or  2  lines  between  the  estimated  and  the  actual 
conjugata  vera  in  30  to  35  cases  which  he  had  meas- 
ured during  life  and  at  autopsy.  Later  experience, 
however,  has  shown  that  Baudelocque's  conclusions 
aw  re  erroneous,  and  that  the  length  of  the  external 
conjugate  gives  a  very  imperfect  idea  of  that  of  the 
conjugata  vera,  since  several  modifying  factors  may 
exist.  Thus,  the  amount  to  be  deducted  varies  with 
the  thickness  of  the  sacrum  and  the  symphysis 
pubis,  and  also  depends,  to  a  great  extent,  upon  the 
elevation  of  the  promontory  of  the  sacrum  and  the 
length  of  the  spinous  process  ofthe  last  lumbar  ver- 
tebra. Unfortunately,  these  factors  cannot  be  accu- 
rately estimated  in  the  living  woman,  and  Skutsch 
has  shown  that  in  100  pelves  examined  bj^  him  the 
difference  between  the  length  of  the  external  and  of 
the  true  conjugate  varied^  from  5.5  to  10  centime- 
tres.  Baisset  has  recently  arrived  at  similar  conclu- 
sions after  studying  120  dried  pelves;  and  at  the 
present  time  I  have  in  my  possession  two  specimens 
whose  true  conjugates  are  of  equal  length,  but 
whose  external  conjugates  show  a  difference  of  5 
centimetres. 

But  although  the  measurement  of  the  external 
conjugate  does  not  give  us  accurate  information 
concerning  the  length  of  the  conjugata  vera,  it 
nevertheless  enables  us  to  draw  certain  important 
conclusions.     Thus,  generally  speaking,  when  the 

former  measures  between  ,20  and  21  centimetres,  the  conjugata  vera  will 
rarely  be  found  to  be  shortened;  when,'  however,  it  measures  between  18^ 
and  19  centimetres,  the  conjugata  vera  is  shortened  in  about  one  half  of 
the  cases;  and  when  it  is  below  17  centimetres  pelvic  contraction  is  almost 
imiforrnly  present. 


Fig.  489. — Michealis's 
Khomboid  (Stratz). 


588  OBSTETRICS 

It  was  formerly  believed  that  one  could  form  a  fairly  accurate  estimate 
of  the  length  of  the  transverse  diameter  of  the  superior  strait  by  making 
certain  deductions  from  the  distances  between  the  anterior  superior  spines 
and  between  the  crests  of  the  ilium.  The  incorrectness  of  this  conclusion, 
however,  was  first  demonstrated  by  Scheffer,  who  showed  that  the  trans- 
verse diameter  of  the  superior  strait  may  be  of  the  same  length  in  two 
pelves,  while  at  the  same  time  the  distances  between  the  iliac  crests  vary 
by  as  much  as  3.3  centimetres.  This  source  of  error  depends  in  great  part 
upon  the  angle  which  the  iliac  fossa  forms  with  the  rest  of  the  innominate 
bone,  and  the  extent  to  which  its  anterior  portion  is  flared  out. 

The  distance  between  the  trochanters  is  the  least  valuable  of  all  the 
external  pelvic  measurements,  as  its  length  depends,  to  a  great  extent,  upon 


Fig.  490. — Measuring  Diagonal  Conjugate. 

the  angle  which  the  neck  of  the  femur  forms  with  its  shaft;  and  as  a  conse- 
quence its  shortening,  unless  very  marked,  does  not  indicate  a  correspond- 
ing decrease  in  the  transverse  diameters  of  the  pelvic  cavity. 

Nevertheless,  despite  many  possible  inaccuracies,  the  external  measure- 
ments are  of  considerable  value,  in  that  they  serve  to  indicate  with  tolerable 
certainty  the  variety  of  pelvis  with  which  one  has  to  deal.  Normally  the 
distance  between  the  spines  is  2.5  to  3  centimetres  less  than  that  between 
the  crests;  but  in  the  rhachitic  pelvis,  owing  to  the  flaring  of  the  iliac  bones, 
this  proportion  becomes  deranged,  and  the  two  diameters  approximate  one 
another  in  length,  the  former  frequently  being  equal  to,  and  occasionally 


EXTERNAL    PELVIMETRY 


589 


exceeding  the  latter.  If,  however,  both  measurements  arc  considerably 
below  the  normal,  but  preserve  their  usual  relation  to  one  another,  and  at 
the  same  time  the  external 
conjugate  is  also  shortened 
proportionately,  it  is  permis- 
sible to  conclude  that  the 
entire  pelvis  measures  below 
normal  in  all  its  diameters,  or, 
in  other  words,  is  generally 
conl  racted. 

Goenner,  iu  1901,  demon- 
strated the  fallacy  of  attempt- 
ing to  diagnose  the  existence 
of  a  contracted  pelvis  by 
external  pelvimetry  alone. 
After  measuring  the  external 
diameters  in  100  cadavers,  he 
compared  them  with  those  of 
the  pelvic  cavity  as  revealed 
at  autopsy,  and  found  that 
whereas  the  former  would 
seem  to  indicate  that  nearly 
all  of  the  pelves  were  contracted,  the  latter  proved  that  such  was  the  case 
in  only  22  instances.  My  own  observations  bear  out  Goenner's  conclusions, 
particularly  in  coloured  women,  in  whom,  had  we  estimated  the  frequency 
of  contracted  pelves  from  external  measurements  alone,  our  figures  would 


Fig.  491.- 


Mka-cp.ing  the  Length  of  Diagonal  Cow- 
jugate   UPON  THE  FlNGERS. 


Fig.  492.  Fig.  493. 

Figs.  492,493. — Diagrams    showing  Variations   in   Length    of  Diagonal  Conjugate  Depend- 
ent upon  the  Height  and  Inclination  of  the  Symphysis  Pubis. 


have  shown  a  frequency  of  about  75  per  cent,  whereas  internal  pelvimetry 
showed  that  in  reality  it  was  only  18.8  per  cent. 

Notwithstanding  all  these  possible  fallacies,  external  pelvimetry  is  of 


590 


OBSTETRICS 


considerable  value  to  the  obstetrician  and  should  not  be  neglected.  In 
private  practice  it  is  my  rule  to  employ  it  at  the  preliminary  examination 
four  to  six  weeks  before  the  expected  date  of  confinement.  If  the  measure- 
ments are  approximately  normal, 
the  patient  being  a  primipara  and 
the  child's  head  fixed  in  the  pelvic 
cavity,  internal  mensuration  is  not 
practised.  But  if  they  are  abnor- 
mal, and  especially  if  the  diagonal 
conjugate  measures  18  centimetres 
or  less,  internal  pelvic  measure- 
ments should  be  resorted  to  no  mat- 
ter what  the  position  of  the  head 
may  be  or  how  many  children  the 
patient  may  have  borne  previously. 
Internal  Pelvimetry.  — -In  the 
vast  majority  of  abnormal  pelves 
the  most  marked  deformity  affects 
the  antero-posterior  diameter  of  the 
superior  strait,  and  as  a  consequence 
we  are  especially  anxious  to  arrive 
at  the  length  of  the  conjugata  vera. 
Unfortunately,  this  cannot  be  measured  directly  in  the  living  woman,  and 
in  practice  it  is  estimated  by  measuring  the  diagonal  conjugate — the  dis- 
tance from  the  promontory  of  the  sacrum  to  the  lower  margin  of  the  sym- 
physis pubis — and  making  a  certain  deduction  from  it.  This  method  was 
introduced  by  Smellie  and  still  further  elaborated  by  Baudelocque. 

Measuring  the  Diagonal  Conjugate. — For  this  purpose  the  patient  should 
be  placed  upon  an  examining  table  with  her  knees  drawn  up.  If  this  cannot 
be  conveniently  arranged,  she  should  be  brought  to  the  edge  of  the  bed  and 
a  firm  pillow  placed  beneath  her  buttocks.  Two  carefully  disinfected  fin- 
gers are  introduced  into  the  vagina,  and  the  anterior  surface  of  the  sacrum 


Fig.  494. — Diagram  showing  Effect  of  Posi- 
tion of  Promontory  of  Sacrum  upon  the 
Length  of  the  Diagonal  Conjugate. 


Fig.  495. — Stein's  Pelvimeter. 


is  methodically  palpated  from  below  upward,  and  its  vertical  and  lateral 
curvature  noted.  At  the  same  time  the  motility  of  the  coccyx  should  be 
tested  by  seizing  it  between  the  fingers  in  the  vagina  and  the  thumb  exter- 


[NTERNAL   PELVIMETRY 


591 


nally.  In  normal  pelves  only  the  last  three  sacral  vertebrae  can  be  felt 
without  pushing  up  the  perinseum,  whereas  in  markedly  contracted  varieties 
the  entire  anterior  surface  of  the  sacrum  is  readily  accessible. 


^.^ 


Fig.  496. — Measuring  Conjugata  Vera  with  Skutscii's  Pelvimeter. 

In  ordinary  cases,  in  order  to  measure  the  diagonal  conjugate  the  elbow- 
is  depressed  and  the  peringeum  forcibly  pushed  upward  by  the  knuckles 
of  the  third  and  fourth  fingers,  while  the  index  and  second  fingers  are  held 
firmly  together  and  directed  upward  in  the  direction  of  the  umbilicus. 
The  promontory  of  the  sacrum  is  soon  felt  by  the  tip  of  the  second  finger 
as  a  projecting  bony  margin  at  the  base  of  the  sacrum.    With  the  finger 


Fig.  497. — Hirst's  Pelvimeter. 


closely  applied  to  its  most  prominent  portion,  the  hand  is  elevated  until 
the  radial  surface  of  the  index  finger  is  brought  into  close  contact  with  the 
pubic  arch.     This  point  is  then  marked  by  the  index  finger  of  the  other 


592 


OBSTETRICS 


hand.,  after  which  the  fingers  are  withdrawn  from  the  vagina  and  the  dis- 
tance between  it  and  the  tip  of  the  second  finger  is  measured  (Figs.  490  and 

491).  This  measurement  gives 
the  diagonal  conjugate,  from 
which  the  true  conjugate  is  es- 
timated by  deducting  1.5  to  2 
centimetres,  according  to  the 
height  and  inclination  of  the 
symphysis  pubis. 

In  this  method  the  prob- 
lem consists  in  estimating  the 
length  of  one  side  of  a  trian- 
gle, the  conjugata  vera;  the 
other  two — the  diagonal  con- 
jugate and  the  height  of 
the  symphysis  pubis1 — being 
known.  Were  we  able  to 
measure  satisfactorily  the  an- 
gle formed  between  the  sym- 
physis and  conjugata  diago- 
nalis,  the  exact  length  of  the 
true  conjugate  could  readily 
be  ascertained  by  the  ordinary 
rules  of  trigonometry;  but 
unfortunately  this  cannot  be 
done  in  the  living  woman, 
and  for  practical  purposes  it  suffices  to  estimate  the  length  of  the  diagonal 
conjugate  as  just  described,  deducting  1.5  centimetre  from  it  if  the  pubis 
is  low  and  s1i>ht1y  in^linprl.  and^2_jjeiitiiiietres  if  it  is  high  and  has  a 
marked  inclination.  The  rationale  of 
this  is  clearly  shown  in  Figs.  492  and 
493.  The  length  of  the  diagonal  conju- 
gate also  varies  according  to  the  position 
of  the  promontory,  being  longer  when  it 
is  elevated,  and  vice  versa  (Fig.  494). 

Since  the  time  of  G.  W.  Stein  (1772), 
numerous  instruments  have  been  devised 
by  means  of  which  the  conjugata  vera 
could  be  directly  measured;  but  unfor- 
tunately the  majority  of  them,  while  the- 
oretically correct,  are  practically  useless 
on  account  of  the  difficulty  of  their  ap- 
plication. Descriptions  and  illustrations 
of  many  of  these  instruments  are  to  be 
found  in  Skutsch's  excellent  monograph. 
Skutsch,  in  1886,  devised  a  pelvimeter 
by  which  the  conjugata  vera  could  be  indirectly  though  accurately  meas- 
ured (Fig.  496).    Hirst  has  more  recently  described  a  simple  device  for  the 


Fig.  498. — Measuring  Transverse  Diameter  of  Supe 
rior  Strait  with  Skutsch's  Pelvimeter. 


Fig.  499. — Breisky's  Method  of  Measur- 
ing Antero-Posterior  Diameter  of 
Pelvic  Outlet. 


INTERNAL    PELVIMETRY 


593 


same  purpose.     Both  of  these  instruments  give  satisfactory  results  when 
properly  used,  bui  their  employment  is  usually  so  painful  to  the  patienl  as 
to  require  the  administration  of  an  anaesthetic.     Naturally,  therefore,  they 
arc  employed  only  in  those  rare  cases  in  which  accurate  information  con 
cerning  the  length  of  the  conjugata  vera  is  urgently  called  for. 

Neumann  and  Ehrenfest,  in  1900,  described  a  complicated  instrument 
— the  pelvigraph — by  means  of  which  the  contour  of  the  anterior  and 
posterior  walls  of  the  pelvis  can  be  graphically  outlined,  and  whence  the 
exact  length  of  the  various  antero-postcrior  diameters  can  be  readily  ascer- 
tained. This  instrument  gives  excellent  results,  but  is  too  complicated  for 
use  outside  of  a  well-regulated  hospital. 

Measuring  the  Transverse  Diameter  of  the  Superior  Strait. — This  diame- 
ter cannot  be  measured  directly  in  the  living  woman,  and  as  a  rule  for 


Fig.  500. — Measuring  the  Distance  between  the  Tubeka  Ischii. 


all  practical  purposes  it  is  necessary  only  to  ^palpate  the  linea  terminal  is 
with  the  examining  fingers,  and  in  this  way  roughly  estimate  the  outlines 
of  the  superior  strait.  If,  however,  we  wish  to  learn  its  exact  length,  it 
can  be  ascertained  indirectly  by  the  employment  of  Skutsch's  instrument. 
Measuring  the  Diameters  of  the  Pelvic  Outlet. — Occasionally  it  is  desir- 
able to  measure  the  diameters  of  the  pelvic  outlet — the  distances  between 
the  lower  margin  of  the  symphysis  pubis  and  the  tip  of  the  sacrum,  and 
between  the  tubera  ischii  respectively.  Breisky  described  a  practical  meth- 
od of  measuring  the  former.  For  this  purpose  the  woman  having  beeu 
placed  on  her  side,  one  end  of  the  pelvimeter  is  introduced  into  the  vagina 
and  applied  to  the  lower  margin  of  the  symphysis  pubis,  the  other  end 
being  applied  over  the  tip  of  the  sacrum  externally.  A  deduction  of  1.5 
centimetre  from  this  measurement  will  give  a  tolerably  accurate  idea  of  the 
antero-posterior  diameter  of  the  inferior  strait. 


594  OBSTETRICS 

The  distance  between  the  tubera  ischii  can  be  approximately  estimated 
by  Schroeder's  method  or  by  a  modification  of  it.  In  the  former  the  tubera 
ischii  are  carefully  palpated  through  the  skin  and  marks  made  with  a  der- 
matographic  pencil  on  the  external  surface  at  points  apparently  corre- 
sponding to  their  inner  margins.  The  distance  between  these  is  then 
measured  with  a  tape-measure.  It  is  often  convenient  to  palpate  the  inner 
margins  of  the  ischial  tuberosities  with  the  thumbs,  so  that  the  nails  are 
directly  over  the  points  to  be  measured,  when  an  assistant  ascertains  the 
distance  between  them  with  Budin's  pelvimeter.  If  precise  information 
is  desired,  it  is  advisable  to  use  the  pelvimeter  described  by  Klien.  By  the 
routine  employment  of  this  instrument,  its  inventor  claims  that  contrac- 
tion of  the  inferior  strait  will  be  found  to  be  of  comparatively  frequent 
occurrence. 

Use  of  X  Rays. — After  the  discovery  of  the  Boentgen  ray  and  the  dem- 
onstration of  the  various  uses  to  which  it  might  be  put,  it  was  thought 
possible  that  it  might  also  afford  a  valuable  method  of  investigating  the 
shape  and  size  of  the  pelvis.  Budin  and  Varnier,  in  1897,  reported  their 
experience  with  it,  and  showed  that,  while  it  often  gave  an  excellent  idea 
of  its  shape,  the  ideas  as  to  size  obtained  by  it  were  erroneous. 

Varnier  continued  to  experiment  with  the  method,  but  although  he 
reported  in  1899  that  he  had  discovered  a  method  \>y  which  it  could  be  em- 
ployed for  estimating  the  actual  size  of  the  pelvis,  no  details  have  as  yet 
been  published. 

A  comprehensive  review  of  the  literature  upon  the  subject  was  given 
by  Mullerheim  in  1898.  Bouchacourt,  in  1900,  devised  a  method  for  which 
he  claimed  excellent  results.  Up  to  that  time  all  radiographs  of  the  pelvis 
gave  distorted  ideas  in  regard  to  its  dimensions,  owing  to  the  fact  that 
the  sacrum  lay  much  nearer  the  sensitive  plate  than  the  symphysis,  and 
consequently  the  anterior  portion  of  the  pelvis  was  enlarged  out  of  all  pro- 
portion to  the  posterior.  This  defect  rendered  out  of  the  question  any 
attempt  to  utilize  the  radiograph  for  purposes  of  mensuration.  Boucha- 
court suggested  that  it  might  be  obviated  by  placing  a  rectangular  metal 
frame  about  the  woman's  hips,  more  or  less  corresponding  to  the  plane  of 
the  superior  strait,  each  side  of  the  frame  being  marked  by  dentations  1 
centimetre  apart.  "When  the  picture  was  taken  these  would  also  be  repro- 
duced, and  on  connecting  the  corresponding  points  upon  the  four  sides  of 
the  picture  a  definite  idea  could  be  obtained  as  to  the  dimensions  of  the 
superior  strait.  The  method,  however,  is  quite  complicated,  and  has  not 
come  into  general  use. 

Classification  of  Contracted  Pelves.- — For  the  first  classification  of  abnor- 
mal pelves  we  are  indebted  to  Deventer,  who  distinguished  three  groups: 
too  large,  too  small,  and  too  flat  pelves. 

Most  recent  attempts  at  classification  have  been  based  upon  the  shape 
of  the  pelvis,  without  taking  into  consideration  the  ^etiological  factors 
which  lead  to  its  production.  This  method  was  adopted  by  Michealis,  and 
reached  its  greatest  perfection  in  Litzmann's  hands.  The  former  thor- 
oughly realized  its  inherent'  defects  and  regretted  that  other  methods  of 
classification  could  not  be  employed.     Kilian,  Busch,  and  Siebold  had  pre- 


Classification  of  contracted  pelves 


►95 


viously  recognised  the  necessity  of  taking  into  account  the  etiological  fac- 
tors which  are  concerned  in  the  production  oi*  pelvic  abnormalities,  but  i  heir 
knowledge  was  too  meagre  to  permit  of  such  a  course. 

It  was  not  until  1889  that  Schauta  was  able  to  suggest  a  fairly  satis- 
factory a'tiological  classification,  which  soon  obtained  general  acceptance, 
although  it  is  still  far  from  ideal.  Tarnier  and  Budin,  in  their  treatise 
issued  in  1898,  followed  somewhat  similar  lines.  Breus  and  Kolisko  do  not 
consider  that  either  are  perfectly  satisfactory,  and  have  suggested  a  sub- 
stitute for  them. 

Owing  to  the  fact  that  our  knowledge  of  the  fundamental  factors  un- 
derlying the  production  of  many  forms  of  abnormal  pelves  is  still  very 
meagre,  and  occasionally  entirely  lacking,  it  is  apparent  that  at  the  present 
time  no  etiological  classification  can  be  perfectly  satisfactory,  though  from 
a  practical  point  of  view  the  one  employed  by  Tarnier  and  Budin  would 
seem  to  approach  more  nearly  to  it. 

For  convenience  of  reference  we  shall  give  the  classifications  of  Tarnier 
and  Budin  and  of  Schauta  in  parallel  columns;  but  although  we  shall  gen- 
erally follow  the  former  in  describing  the  several  varieties,  we  shall  not 
necessarily  adhere  to  the  order  in  which  the  different  groups  are  arranged. 


Tarxier  axd  Budix's  Classification 

I.  Pelvic  Anomalies  due  to  Excess  of  Mal- 
leability of  Pelvic  Bones : 
(")  Rhachitic  pelvis. 

(b)  Flat,  non-rhachitic  pelvis. 

(c)  Osteomalacic  pelvis. 


II.  Anomalies    due    to   Abnormal    Trans- 
mission of  the  Body  WeigJit  to  Pelvis  : 

(a)  Lordosis. 

(b)  Scoliosis. 

(c)  Kyphosis. 

III.  Anomalies  resulting   from   Abnormal 

Articulation  of  the  Vertebral  Column 
with  the  Sacrum  : 

(a)  Spondylolisthesis. 

(b)  Spondylizeme. 

IV.  Anomalies  resulting  from  the  Abnor- 

mal Direction  of  the  Upward  and  In- 
ward Force  exerted  by  the  Femora: 

(a)  Unilateral  lameness. 

(b)  Bilateral  lameness. 


39 


Schauta's  Classificatiox 

II.  Pelvic  Anomalies  resulting  from  Dis- 
eases of  the  Pelvic  Bones : 

(a)  Rhachitic  pelvis. 

(b)  Osteomalacic  pelvis. 

(c)  New  growths. 

(d)  Fracture. 

(e)  Atrophy,  caries,  and  necrosis. 

IV.  Anomalies  resulting  from  Diseases  of 

the  Superimposed  Skeleton  : 

(a)  Spondylolisthesis. 

(b)  Kyphosis. 

(c)  Scoliosis. 

(d)  Kyphoscoliosis. 

(e)  Lordosis. 

(/)  Anomalies  resulting  from  the  fusion  of 
the.  last  lumbar  with  the  first  sacral 
vertebra,  as  well  as  of  the  first  sacral 
vertebra  with  the  iliac  bones  (assimi- 
lation pelvis). 

V.  Anomalies  resulting  from  Abnormalities 

of  the  Subjacent  Skeleton: 

(a)  Coxitis. 

(b)  Luxation  of  the  head  of  the  femur. 

(c)  Luxation  of  the  heads  of  both  femora. 

(d)  Unilateral  or  bilateral  club-foot. 

(e)  Absence   or   deformity   of  one  or  both 

lower  extremities. 


596 


OBSTETRICS 


Tarnier  and  Budin's  Classification 
V.  Anomalies    resulting    from    Primary 
Defects  in   the  Development  of  the 
Pelvic  Bones : 
(a)  Generalized  and  symmetrical : 

1.  Excess  of  general  development  (jus- 

to  major  pelvis). 

2.  Lack  of  general  development  (gen- 

erally contracted  pelvis). 

(i)  Localized  and  asymmetrical : 

1.  Obliquely  contracted  (Naegele)  pel- 
vis. 

(c)  Localized  and  symmetrical : 

1.  Double  oblique  (Robert)  pelvis. 

2.  Split  pelvis. 

3.  Ossification  of  sacro-iliac  joints. 

4.  Arrest  of  development  of  the  body 

of  the  sacrum. 

VI.  Atypical  Deformities : 

Tumours  and  fractures  of  the  pelvic  bones. 


Schauta's  Classification 
I.  Anomalies  resulting  from  Faulty  De- 
velopiment  : 

(a)  Generally  contracted  pelvis. 

(b)  Simple  flat,  non-rhachitic  pelvis. 

(c)  Generally  contracted  flat  pelvis. 

(d)  Narrow,  funnel-shaped  foetal  or  unde- 

veloped pelvis. 

(e)  Imperfect  development  of  one  sacral  ala 

(Naegele  pelvis). 
(/)  Imperfect  development  of  both  sacral 

alse — Robert  pelvis. 
(g)  Generally,  equally  enlarged  (justo  major 

pelvis). 


III.  Anomalies  in  the  Articulation  of  the 

Pelvic  Bones  : 
(a)  Abnormally  firm  union  (synostosis) : 

1.  Of  the  symphysis. 

2.  Of  one  or  both  sacro-iliac  synchon- 

droses. 

3.  Of  the  sacrum  with  the  coccyx. 


LITERATURE 

Arantius.     See  Chapter  I. 

Baisset.     De  la  mensuration  externe  du  bassin.     These  de  Lyon,  1901. 

Barnes.     Internat.  GynaBcolog.  Congress,  Geneva,  1896.     Centralbl.  f.  Gyn.,  1896,  1089. 

Baudelocque.    L'art  des  aceouchements.     Nouvelle  ed.,  1789,  t.  I,  76-90. 

Bouchacourt.     De  la  radiographic  du  bassin  de  la  femme  adulte.     L'Obstetrique,  1900, 

v,  320-351. 
Breisky.     Beitrage  zur  geburtshiilflichen  Beurtheilung  der  Verengerungen  des  Becken- 

ausganges.     Wien.  med.  Jahrb.,  1870,  xix. 
Breus  und  Kolisko.     Die  pathologischen  Beckenformen.     Wien,  1900,  Theil  I. 
Budin.     Statistiques  de  la  Maternite  de  Paris.     L'Obstetrique,  1896,  iii,  134. 

Photographie  par  les  rayons  x  d'un  bassin  de  Naegele.     L'Obstetrique,  1897,  ii,  493. 
Busch.     Geburtskunde,  Berlin,  1849. 
Crossen.     Partial  Report  of  Eight  Hundred  Cases  of  Labour.     Amer.  Gyn.  and  Obst. 

•Jour.,  1898,  xiii,  53. 
Davis.  Frequency  and  Mortality  of  Contracted  Pelves.    Amer.  Jour.  Obst.,  1901,  xli.  11-1 5. 
Deventer.     Operationes  chirurgicae  novum  lumen  exhibentes  obstetricantibus,  1701. 
Dewees.     A  Compendious  System  of  Midwifery.     Philadelphia,  1824. 
Dionis.     Traite  general  des  aceouchements,  etc.     Paris,  1718. 

Flint.     Deformed  Pelves.     Rep.  of  Soc.  of  the  Lying-in  Hosp.,  New  York,  1897,  258-271. 
Fuchs.     Statistik  der  in  den  letzten  10  Jahren  in  der  Erlanger  Universitats-Frauenklinik 

vorgekommenen  engen  Becken.     D.  I..  Wiirzburg,  1899. 
Glaser.     Ueber  spontane  Geburten  bei  engen  Becken.     D.  I.,  Miinchen,  1898. 
Goenner.     Zur  statistik  des  engen  Beckens.     Zeitschr.  f.  Geb.  u.  Gyn.,  1882,  vii,  314. 
Ein  hundert  Messungen  weiblicher  Becken  an  der  Leiche.     Zeitschr.  f.  Geb.  u.  Gyn., 

1901,  xliv,  308-325. 


CONTRACTED   PELVIS  597 

Beinsios.     Die  Geburten  bei  engen  Becken  in  den  Jahren,  1894-'97.    D.  I..  Breslau,  ls'.>^. 
Hirst.    American  Text-Book  of  Obstetrics,  1897,  498-510. 

Kilian".     Die  Geburtslehre  von  Seiten  der  Wissenschaft  und  Kunst  dargestellt.     Frank- 
furt. 1840. 
Kxien.     I ) it-  geburtshillfliche  Bedeutung  derVerengerungen  des  Beckenausgangs.    Volk- 

mann's  Sammlung  klin.  Vortrage,  N.  1'..  Nr.  169. 
Kxaim'.     Bericht  iiber  105  Geburten  bei  engen  Becken  aus  den  Jahren  1881-95.    Archiv 

f.  Gyn.,  1886,  xl.  489-586. 
KOttoen.     Zur  Statistik  des  engen  Beekens.     D.  I.,  Bonn,  1895. 
Leopold  (Franke).     Enges  Becken  und  spontane  Geburt.     Arbeiten  aus  d.  konigl.  Frau- 

enklinik  in  Dresden,  1895,  ii.  29-48. 
Litzmaxx.     Die  Forinen  des  Beekens.     Leipzig.  1861. 

Die  Geburt  bei  engen  Becken.     Leipzig,  1884. 
Ludwig  und  Savor.     Klin.  Bericht  iiber  die  Geburten  bei  engen  Becken  in  den  Zeitraura 

18?8-'92.     Bericht  aus  der  II.  geb.  gyn.  Klinik  in  Wien,  R.  Chrobak,  1897,  120-594. 
Lusk.     The  Science  and  Art  of , Midwifery.     Fourth  ed.,  1895. 
Maubiceau.     Observations  sur  la  grossesse  et  l*accouchement  des  femrnes.     Xouv.  ed., 

1738. 
Michealis.     Das  enge  Becken.     Leipzig,  1851. 

de  la  Motte.     Traite  cornplet  des  accouchements  naturels.  etc.     Xouv.  ed.,  Leiden,  1729. 
Muller.     Zur  Frequenz  und  Aetiologie  des  allgemeinen  verengten  Beekens.     Archiv  f. 

Gyn.,  1880.  xvi.  155. 
Mullerheim.     Verwerthung  der  Rontgen  Strahlen  in  der  Geburtshiilfe.     Deutsche  med. 

Wochenschr.,  1898,  Nr.  39. 
Naegele.     Das  weibliehe  Becken,  etc.     Carlsruhe,  1839. 

Das  schrag  verengte  Becken.  etc.     Mainz,  1839. 
Neumann  und  Ehrexfest.     Eine  neue  Methode  der  inneren  Beckenmessung  an  der  leben- 

den  Frau.     Monatsschr.  f.  Geb.  u.  Gyn.,  1900.  xi.  237-253. 
Pare.     See  Chapter  I. 

Pawlik.     Internat.  Gyn.  Congress.  Geneva.  1896.     Centralbl.  f.  Gyn.,  1896.  1090. 
Pfuxd.     Aerztl.  Intelligenzblatt.  1895.  xxxii,  247. 

Pixard.     Fonctiomnent  de  la  Maison  d'accouchement  Baudelocque.     For  various  years. 
Puzos.     Traite  des  accouchements.  etc.     Paris.  1749. 

Reynolds.    The  Frequency  of  Contracted  Pelves.     Tr.  Am.  Gyn.  Soc.  1890.  xv,  367-377. 
Schauta.     Die  Beckenanomalien.     Muller's  Handbuch  der  Geb.,  Bd.  II.  1889. 
Scheffer.     Leber  das  Verhaltniss  des  Abstandes  der  Spinae  und  Cristae  ilium  an  dem 

des  Querdurchmesser  des  Beckeneinganges.     Monatsschr.  f.  Geb.,  1868,  xxxi,  299-309. 
Skutsch.     Die  Beckenmessung.     Jena.  1886. 

Die  praktische  Verwerthung  der  Beckenmessung.     Deutsche  med.  Woch..  1891,  Xr.  21. 
Siebold.     Lehrbuch  der  Gebuitshulfe.  1854. 
Smellie.     Treatise  on  the  Theory  and  Practice  of  Midwifery,  with  Collection  of  Cases. 

Eighth  ed..  London,  1774. 
Steix.  G.  W.     Beschreibung  des  kleinen  und  einfachen  Beckenmesser,  etc.     Klein  Werke 

zur  prak.  Geburtsh..  Marburg.  1798.  135. 
Varxier.     Etude  anat.  et  radiographique  de  la  symphyse  pubienne  apres  le  symphyseo- 

tomie.     Compt.es  rendus  de  la  Soc.  d'obst.,  de  gyn.  et  de  paed.  de  Paris,  1899,  i,  208. 
Wiedexmuller.     Zur  Statistik  des  engen  Beekens.     D.  I..  Marburg.  1895. 
Williams.  J.  Whitridge.     Pelvimetry  for  the   General   Practitioner.     Medical   Xews. 

March  21.  1891. 
Frequency  of  Contracted  Pelves  in  Baltimore.   Johns  Hopkins  Hosp.  Bulletin,  Aug..  1896. 
Frequency  of  Contracted  Pelves  in  the  first  One  Thousand  Women  delivered  in  the  Ob- 
stetrical Department  of  the  Johns  Hopkins  Hospital.     Obstetrics.  1899.  i.  Xos.  5  and  6. 
Pelvic  Indications  for  the  Performance  of  Csesarean  Section.     Amer.  Medicine,  1901,  ii. 
483-488. 


CHAPTEE    XXXIV 

ANOMALIES  DUE   TO  ABNORMAL  MALLEABILITY  OF   THE 
PELVIC  BONES 

Flat  Non-Rhachitic  Pelvis. — This  is  the  most  frequent  variety  of  pelvic 
deformity  occurring  in  white  women,  but  it  is  comparatively  rare  in  the 
black  race.  It  was  noted  in  43  per  cent  of  the  72  contracted  pelves  de- 
scribed by  Michealis.  Litzmann  stated  that  its  frequency,  as  compared 
with  that  of  the  rhachitic  pelvis,  was  as  7  to  5.  In  our  material  at  the  Johns 
Hopkins  Hospital  it  constituted  49.33  per  cent  of  the  contracted  pelves 
occurring  in  white  women,  as  compared  with  9.86  of  those  in  coloured 
women. 

Most  German  authors  confirm  the  statements  of  Michealis  and  Litz- 
mann as  to  its  frequency.  On  the  other  hand,  Ahlfeld  dissents  from  this 
view,  holding  that  many  of  the  pelves  which  have  been  designated  as  of 
the  simple  flat  variety  are  really  of  rhachitic  origin,  and  Tarnier  and  Budin 
state  that  only  one  sixteenth  of  the  abnormal  pelves  with  which  they  met 
could  be  attributed  to  other  causes  than  rhachitis. 

This  variety  is  frequently  described  as  the  pelvis  plana  Deventeri,  or 
simple  fiat  pelvis,  although  it  is  doubtful  whether  Deventer  differentiated 
between  it  and  the  rhachitic  form.  It  was  accurately  described  by  Betschler 
in  1832,  but  Michealis  and  Litzmann  were  the  first  to  insist  upon  its 
importance  and  frequent  occurrence. 

The  characteristic  feature  of  the  flat  non-rhachitic  pelvis  consists  in  a 
shortening  of  all  the  antero-posterior  diameters  of  the  pelvic  cavity,  while 
the  transverse  measurements  remain  practically  normal.*  This  condition 
is  due  to  the  fact  that  the  entire  sacrum  approaches  more  nearly  than 

*  The  illustrations  in  the  chapters  on  Contracted  Pelves  have  been  prepared  with  the 
greatest  care  and  accuracy.  The  half-tone  illustrations  are  exactly  one  third  natural  size. 
Those  from  specimens  in  our  possession  were  drawn  from  photographs  which  were  taken 
with  the  pelvis  as  nearly  as  possible  in  the  same  position — that  is,  with  the  tip  of  the 
coccyx  and  upper  margin  of  the  symphysis  pubis  on  the  same  horizontal  level.  Accord- 
ingly, the  various  illustrations  can  be  accurately  compared. 

The  diagrams  of  the  superior  strait  and  the  sagittal  sections  through  the  pelvic 
cavity  are  one  sixth  natural  size,  and  are  accurate  to  within  one  millimetre.  The  former 
were  made  by  means  of  the  camera  with  the  pelvis  held  so  that  the  plane  of  its  superior 
strait  was  at  a  right  angle  to  the  horizon.  The  latter  were  made  from  tracings  of  casts 
of  the  pelvic  cavity  obtained  by  means  of  dental  wax,  which  were  then  reduced  by  the 
pantograph. 

598 


FLAT    NON    iniACIHTlC    PELVIS 


599 


norma]  to  the  symphysis  pubis.  At  the  same  time  it  undergoes  a  slight 
rotation  about  its  transverse  axis,  since  the  contraction  is  always  more 
marked  in  the  antero-posterior  diameter  of;  the  superior  than  in  that  of  the 


Fig.  503. 
Figs.  501-503. — Flat  Non-Ehachitic  Pelvis. 

inferior  strait.  The  degree  of  contraction  is  usually  not  very  pronounced, 
and  it  is  rare  to  find  the  conjugata  vera  measuring  less  than  8  centimetres. 
In  fact,  whenever  this  limit  is  passed  the  probability  that  one  has  to  deal 
with  a  flat  rhachitic  pelvis  should  always  be  borne  in  mind. 

The  sacrum  does  not  present  the  characteristic  features  of  rhachitis,  and 
preserves  its  normal  vertical  and  side  to  side  concavity.  Occasionally  it 
may  appear  somewhat  more  delicately  shaped  than  usual,  and  be  narrower 
transversely.  Under  such  circumstances  the  transverse  diameters  of  the 
pelvic  cavity  are  slightly  decreased. 

In  not  a  few  pelves  of  this  character  the  line  of  ossification  between 
the  first  and  second  sacral  vertebra?  is  more  marked  than  usual,  thus  giving 
rise  to  a  so-called  second  or  accessory  promontory. 

/Etiology. — Unfortunately  we  are  not  able  to  make  positive  statements 
as  to  the  cause  of  this  deformity.  By  many  it  is  believed  that  the  approach 
of  the  sacrum  to  the  symphysis  resrdts  from  the  carrying  oflieavy  burdens 
upon  the  back  or  head  during  early  life,  though  such  an  explanation  can- 
not apply  to  all  cases,  especially  in  this  country,  where  it  is  unusual  for 
girls  to  carry  heavy  loads.  In  other  cases  the  condition  is  attributed  to 
the  fact  that  the  child  was  allowed  to  sit  up  at  too  early  an  age  and  for  too 
long  periods. 


600 


OBSTETRICS 


Ahlfeld,  Tarnier,  and  others  think  that  a  part  in  the  production  of 
the  deformity  is  played  by  rhachitis,  which,  they  hold,  may  be  present  in 
a  larval  form  without  giving  rise  to  its  usual  and  characteristic  mani- 
festations!    It  is   quite  possible  that  this  may  be  true  in  many   cases, 
,    _        but    in    others   no   history   even    suggestive   of 
.".."'  ,r      •     ,  rhachitis  in  childhood  can  be  elicited. 

•    „     -    _  -  .-  J  Fehling  and  Schliephake  consider  that  this 

cn    „  -    -    -.   1-  \  ■  variety  of  pelvic  anomaly  is  congenital  in  a  cer- 

tain number  of  instances,  as  they  have  shown 
that  the  jDelves  of  newly  born  children  may  oc- 
casionally present  a  flattened  appearance.     In 

several  cases  studied  by  them  the  relation  be- 

~1  *""  *-"""--"•"£".?        tween  the   conjugata   vera  and  the    transverse 

diameter  of  the  superior  strait  was  as  100  to 

\    <  r4\  I  s  145,  100  to  160,  or  100  to  177,  instead  of  100 

*  '  '  ~   ' «    •*".  -~ "  to  122,  as  is  usually  the  case.     Under-such  cir- 

,  *  'J.    '  <  ,     ?'-'-         cumstances  the  mechanical  factors  above  alluded 

•  %  Or  r 

Z> •  ~  -*"■      '  ,  '■  ,  ^   *         to  could  certainly  not  have  come  into  play. 
cc  C  r    - 1',  c'r  -9  ~  -    ■  Diagnosis. — The  presence   of   a   simple  flat 

r  *  ,  C~  *J  ~  "  pelvis,  as  a  rule,  is  readily  diagnosed.  By  ex- 
ternal pelvimetry  the  distances  between  the 
spines  and  crests  of  the  ilium  and  that  between 
the  trochanters  are  found  to  be  approximately 
rmal,  whereas  Baudelocque's  diameter  is_more 
r  less  shortened.  On  internal  examination  the 
diagonal  conjugate  is  found  to  be  shortened,  and 
the  entire  anterior  surface  of  the  sacrum  appears 
to  be  nearer  the  symphysis  than  usual,  but  pre- 
sents its  normal  curvatures.  There  is  no  widen- 
ing of  the  transverse  diameter  of  the  pelvic  out- 
let, as  in  the  rhachitic  form. 

The  consideration  of  the  effect  of  the  flat 
pelvis  upon  the  course  of  labour,  and  the  treat- 
ment of  such  cases,  will  be  deferred  until  the  flat 
rhachitic  pelvis  is  studied,  as  there  is  no  essential 
difference  in  the  mechanism  of  the  two  varieties. 
Rhachitic  Pelves. — In  many  parts  of  Europe 
the  most  prominent  factor  in  the  production  of 
contracted  pelves  is  an  abnormal  softening  of 
the  bones  in  early  life  resulting  from  rhachitis. 
In  this  country  the  disease  is  observed  compara- 
tively rarely  in  white  children,  occasionally  in 


&mm 


tdo 


Zo-V£t 

Fig.  504.  —  Section  through 
Norjial  Epiphysis  of  Child 
(Spillmann). 

cm.,  normal  cartilage ;  cs.,  carti- 
lage cells  arranged  in  parallel 
rows ;  cc,  area  of  preliminary 
calcification ;  em.,  medullary 
spaces ;  o.,  osteoblasts ;  lo., 
osseous  lamella?. ;  m.,  marrow. 


coloured  children  inhabiting  the  country  districts,  and  very  frequently  in 
those  living  in  large  cities. 

In  not  a  few  cases  the  disease  undergoes  spontaneous  cure,  so  that  no 
trace  of  its  existence  can  be  discovered  in  later  life;  while  in  many  instances 
permanent  skeletal  deformities  result  which  are  not  infrequently  localized 
m  the  pelvis.    Again,  it  is  also  not  unusual  to  meet  with  women  who  to  all 


PATHOLOGY    OK    KHACIIITIS 


601 


appearances  are  quite  normally  formed,  bul  whose  pelves  upon  examination 
present  rhachitic  deformities.  Six  and  fifteen  [mndredl  lis  per  cent  of  the 
abnormal  pelves  occurring  in  i  lie  w  1 1 ft < ■,  and  82J5 1  per  cent  in  the  coloured 
women  delivered  a1  the  Johns  Eopkins  Eospital  were  .rhachitic  in  origin, 
thus  showing  that  even  in  this  country  the  disease  is  of  not  a  little  impor- 
tance from  an  obstel  rical  standpoint. 

Nature  and  Pathology  of  BhacMtis. — Before  describing  the  various 
changes  in  the  pelvis  which  may  result  from  rhachitis,  it  will  be  well  to 
consider  briefly  the  nature  ami  pathology  of  the  disease. 

According  to  Kassowitz,  Spillmann,  and  others,  rhachitis  is  to  be  looked 
upon  as  an  osteitis  associated  with  an  excessive  format  ion  of  osteoid  tissue  al 
the  epiphyses  and  beneath  the  periosteum  of  the  long  bones,  as  well  as  in 
tin-  flat  hones  of  the  skull  and  pelvis.  This  proliferation  is  accompanied 
by  defective  calcilicajion  of  the  newly  formed  tissue,  Zweifcl  stating  that 
only  18  to  24  per  cent  of  inorganic  salts~are  present  in  rhachitic,  as  against 
63  to  65  per  cent  in  normal  bone. 

It  is  customary  to  distinguish  three  stages  in  the  disease:  that  of  con-^ 
gesjjon.  that  of  softening,  and  that  of  progressive  deformity  or  cure,  as 
the  ease  may  be.  In  the  stage  of  con- 
gestion  there  is  a  great  increase  in  vas- 
cularity, which  is  most  marked  at  the 
union  of  the  articular  cartilages  with 
the  diaphyses  of  the  long  bones  and 
also  beneath  the  periosteum. 

In  studying  the  epiphysis  of  a  long 
bone  at  this  period,  we  find  that  the 
zone  of  preliminary  cajcificatipp — 
Truerin's  line — is  slightly  thickened, 
and  its  lower  portion  adjacent  to  the 
newly  formed  spongy  bone  is  perfo- 
rated by  numerous  vascular  loops.  A 
similar  condition  may  also  be  observed 
beneath  the  periosteum  covering  the 
long  and  the  flat  bones  (Fig.  505). 

In  the  second  stage,  while  Gkierin's 
line  has  become  markedly  thickened  and 
very  irregular,  the  vascular  prolifera- 
tion has  advanced  to  a  marked  degree. 
Under  the  microscope,  the  former  is 
seen  to  be  broken  up  in  all  directions 
by  the  rapidly  growing  vascular  loops 
which  subdivide  it  into  large  numbers  of  small,  irregularly  shaped  calcific 
areas.  At  the  same  time  the  formation  of  osseous  tissue  just  beneath  it 
proceeds  in  an  irregular  manner,  ossification  either  failing  to  occur  or  tak- 
ing place  imperfectly.  The  newly  formed  tissue  is  penetrated  in  all  direc- 
tions by  vascular  loops  which  break  it  up  into  small  masses,  between  which 
and  the  marrow  cavities  is  a  considerable  formation  ot  connective  tissue, 
with  spindle-  and  star-shaped  cells,  which  does  not  become  ossified  at  all. 


2> 


Fig.  505. — Section  through  Epiphysis  in 
Eap.ly  Stages  of  Rhachitis  i  Spillmann). 

cs..  cartilage  cells  arranged  in  parallel  rows  ; 
tec,  area  of  preliminary  calcification  ;  c, 
capillary;  tc.  unossified  connective  tissue. 


602 


OBSTETRICS 


To  summarize  these  changes  briefly,  one  may  say  that  the  growing  end 
of  the  bone,  instead  of  undergoing  normal  ossification,  consists  in  great 
part  of  dilated  capillaries  which  separate  irregularly  shaped  masses  of  cal- 
cified cartilage  from  areas  of  connective  tissue  and  imperfectly  formed  bone 


ice— 


g ; 


W  ,* 


¥ig.  506. — Section  through  Epiphysis  in.  Advanced  Stages  of  Khachitis  (Spillmann). 
tec,  area  of  preliminary  calcification  ;  cc,  calcified  cartilage  ;  c,  capillaries  ;  tc,  connective  tissue. 

(Fig.  506).  More  or  less  similar  changes  take  place  under  the  periosteum 
of  the  long  and  flat  bones,  so  that  the  shaft  of  the  bone  soon  becomes 
converted  into  a  spongy  tissue  corresponding  closely  to  that  observed  at 
the  epiphyses. 

In  the  third  period  these  changes  continue  until  death  occurs;  or,  if 
recovery  ensues — the  usual  outcome — there  is  a  progressive  decrease  in 
vascularity,  and  the  normal  process  of  ossification  is  resumed,  so  that  after 
a"  Time  the  only  trace  of  the  disease  is  to  be  found  in  a  thickening  of  the 
bone,  not  infrequently  associated  with  an  increased  porosity.  It  is  there- 
fore apparent  that  the  bones  become  abnormally  soft  and  yielding  in  the 
acute  stages  of  the  disease,  so  that  if  the  child  uses  its  extremities  at  the 
time,  more  or  less  marked  deformities  of  the  various  bones  must  result, 
depending  upon  the  mechanical  conditions  which  are  liable  to  modify  the 
evolution  of  the  infantile  pelvis. 

Forms  of  Rhachitic  Pelves. — As  has  already  been  said,  the  rhachitic  type 
is  one  of  the  most  frequently  observed  varieties  of  contracted  pelvis,  and 
in  extreme  cases  presents  the  most  marked  deformities  with  which  we  are 
familiar,  with  the  exception  of  those  resulting  from  osteomalacia.  Fortu- 
nately, however,  the  degree  of  contraction  is  usually  not  very  pronounced, 


FLAT   RHACHITIC   PELVIS 


603 


Tarnier  having  slated  thai  the  conjugata  vera  measured  Less  than  8.5  cen- 
timetres in  only  l  1. 1  per  eent  of  the  L,020  rhachitic  pelves  studied  by  him. 
With  the  exception  of  the  eases  which  are  complicated  by  abnormalities 
of  the  vertebral  column,  or  by  deformities  gh  ing  rise  to  a  marked  difference 
in  the  Length  of  the  Limbs,  rhachitic  pelves  are  usually  classified  as  follows: 


l;l at  rhachitic  pelvis. 

(u'lmralk  contracted,  Hat  rhachitic  pelvis. 

Generally  and  equally  contracted  rhachitic  pelvis. 


Pseudo-osteomalacic  pelvis. 

Flat  Rhacliitic  I'clris.' — This  variety  corresponds  with  the  flat,  non- 
rhachitic  pelvis,  in  so  far  thai  the  greatest  contraction  occurs  in  the  antero- 
posterior diameter  of  the  superior  strait,  while  the  transverse  diameter  is 

seldom  affected,  or  may  even  be  slightly  longer  than  usual.     At  the  same 
time  it  differs  materially  from  it  in  several  particulars. 


Fig.  508 


Fig.  509. 
Figs.  507-509. — Flat  Rhachitic  Pelvis. 


Generally  speaking,  the  bgii£s  are  less  dense  in  texture  than  usual,  and 
not  infrequently  are  delicate  in  form,  though  occasionally  they  may  appear 
clumsy  and  swollen.  Owing  to  the  marked  lordosis  which  not  infrequently 
results  from  rhachitis,  the  pelvic  inclination,  as  a  rule,  is_ considerably 
increased. 


604 


OBSTETRICS 


The  most  important  changes,  however,  are  to  be  noted  in  the  sacrum 
and  in  the  relation  which  it  bears  to  the  rest  of  the  pelvis,  the  whole  bone 


Fig.  510. — Accentuation"  of  Vertical  Con- 
cavity of  Sacrum  in  Rhachitis. 


Fig.  511. — Showing  Obliteration  of  Vertical 
Concavity   of  Sacrum  in  Rhachitis. 


being  rotated  forward  in  such  a  manner  that  its  promontory  lies  at  a  lower 
lejjiLthan  usual  and  encroaches  markedly  upon  the  area  ofthe  superior 
strait.  Moreover,  the  entire  bone  is  usually  sharply  bent  upon  itself  in  the 
neighbourhood  of  its  third  vertebra,  its  vertical  concavity  becoming  mark- 
edly accentuated.  In  extreme  cases  the  upper  portion  of  it's  anterior  surface 
extends  almost  horizontally,  while  the  lower  portion  looks  upward  and  for- 
ward. At  the  same  time  the  bodies  of  the  individual  vertebrae  are  pushed 
out  beyond  the  level  of  their  ala?,  the  lateral  concavity  of  the  sacrum  being 
thereby  diminished,  and  not  infrequently  becomes  converted  into  a  con- 
vexity. Occasionally  the  lower  extremity  of  the  sacrum  and  the  coccyx  are 
not  bowed  inward,  and  in  such  cases  the  former  bone,  instead  of  present- 
ing an  increased  vertical  concavity,  may  be  straight  or  even  convex  from 
above  downward. 

It  is  not  unusual  for  the  body  of  the  first  sacral  vertebra  to  be  more 
markedly  displaced  forward  than  those  below  it,  so  that  its  lower  margin 
projects  beyond  the  general  surface,  when  it  can  be  felt  as  a  false  promon- 
tory. Under  such  circumstances  the  distance  between  it  and  the  symphysis 
pubis  is  frequently  the  shortest  antero-posterior  diameter  of  the  pelvis. 

As  the  upper  part  of  the  sacrum  becomes  displaced  downward  and 
inward,  its  posterior  surface  recedes  from  the  superior  pn^prinv  spines  of 
the  ilium,  which  approach  one  another  more  closely  than  in  the  normal 
condition. 

The  iliac  bones,  in  addition  to  being  more  delicately  shaped  than  usual, 
are  directed  almost  horizontally,  and,  what  is  more  important,  flare  outward 
to  a  marked  degree,  so  that  the  distance  between  their  anterior  superior 
spines  approaches  that  between  their  crests,  and  occasionally  even  exceeds 
it  in  length.  Xot  infrequently  the-  iliac  bones  bend  just  in  front  of  the 
sacro-iliac  synchondrosis,  so  that  the  Hio-pectineal  line,  instead  of  follow- 
im^a  gen  Lie  CUl've^  forms"  a  sharp  angle  at  that  point,  thus  adding  materially 
to  the  narrowing  of  the  superior  strait.  At  the  same  time  the^ajcetabnla 
are  displaced  forward  and  come  to  lie  upon  the  anterior,  instead  of  upon 
the  lateral  "portion  of  the  pelvic  ring.     The  pubic  arch  is  somewhat  wider 


FLAT    KHACIHTIC    PELVIS 


605 


than  usual,  and  the  tulnTii  isc-hii  art'  everted,  so  that  the  i  rang]  erse  diam- 
eter of  the  pelvic  out  lei  appears  to  be  exaggerated,  and  occasionally  meas- 
ures more  than  in  the  normal  pelvis. 

These  changes  exerl  a  decided  imluence  upon  the  shape  of  the  pelvic 
cavity,  the  effed  being  mosl  marked  in  the  superior  strait,  which  may 
become  oval,  reniform,  or  even  I  nan -shaped  in  outline,  according  to  the 
degree  of  displacement  of  the  promontory  of  the  sacrum.    The  conjugata 


vera  is  always  shortened,  while  the  transverse  diameter  seems  to  be  en- 


larged,  although  this  may  be  only  apparent  unless  the  pelvis  be  of  large  size. 


Fig.  513.  Fig.  514. 

Figs.  512-514. — Flat  Eiiachitic  Pelvis,  shovtixg  Double  Peoiioxtoby. 


Owing  to  the  approach  of  the  anterior  and  posterior  walls  of  the  pelvis, 
the  oblique  diameters  of  the  superior  strait  are  always  shortened,  as  are 
also  the  sacro-cotyloid  diameters.  As  a  result  of  the  upward  and  backward 
displacement  ofthe  lower  portion  of  the  sacrum,  the  pelvic  cavity  below 
the  superior  strait  undergoes  a  relative  increase  in  size,  which  is  more  par- 
ticularly marked  in  the  various  antero-posterior  diameters. 

In  occasional  cases  sharp  exostoses^  may  make  their  appearance  upon  the 
pubic  crests,  the  ilio-pectineal  eminences,  and  in  front  of  the  sacro-iljac 
synchondroses — pelvis  spinosa.  "When  such  structures  are  not  well  covered 
by  soft  parts,  they  may  lead  to  serious  injuries  of  the  uterus  at  the  time  of 
labour. 


606 


OBSTETRICS 


2.  Generally  Contracted.  Flat  Jiliacliitic  Pelvis. — It  is  in  this  variety  of 
pelvis  that  marked  degrees  of  contraction  are  often  encountered,  the  eon- 
jugata  vera  sometimes  heing  reduced  to  3  or  -f  centimetres.  This  pelvis 
corresponds  closely  to  the  ordinary  flat  rhachitic  type,  except  that  the 
shortening  applies  to  all  its  diameters  instead  of  being  limited  to  the 
conjugata  vera. 

The  decrease  in  size  is  particularly  marked  in  the  sacrum,  which  may 
present  a  considerable  diminution  in  its  transverse  measurements.  The 
small  size  of  the  pelvis  in  such  cases  may  be  due  either  to  atrophic  changes 
in  the  bones  resulting  from  the  rhachitis  itself  or  to  a  primarily  small  pelvis 
that  has  become  affected  with  the  disease. 


Fig.  515. 


Fig.  516. 

Fig.  517. 
Figs.  515-517. — Generally  Contracted,  Flat  Rhachitic  Pelvis. 

3.  Generally  Equally  Contracted  Bhachitic  Pelvis. — This  variety  was  first 
described  by  Michealis,  and  according  to_most~"authors  is  observed  but 
rarely.  Miiller,  however,  considers  that  not  a  few  cases  which  were  pre- 
viously described  as  instances  of  simple,  generally  contracted  (justo-minor) 
pelvis,  belong  under  this  category,  and  my  own  experience,  particularly  in 
the  negro  race,  has  tended  to  confirm  his  observations. 

According  to  Litzmann,  this  type  differs  from  the  justo-minor  pelvis 
in  its  ungainly  and  angular  appearance,  and  in  the  marked  prominence  of 
the  pubic  crests^    Thesivperior  strait  appears  to  be  equally  shortened  in  all 


UKNKKAUA    lOXTKA(TKI)    Kll  ACIIITK'    I'KLVIS 


607 


its  diameters  instead  of  merely  flattened,  while  the  rest  of  the  pelvis  pre- 
sents  indisputable  signs  of  a  past  rhachitis,  which  is  more  particularly 
marked  in  the  sacrum  and  in  the  eversion  of  the  tubera  ischii. 


! 


*  1      / 

5  /'  • 


K, 


\X<9 


Fig.  519. 

Fig.  520. 
Figs.  518-520. — Generally  Equally  Contracted  Ehachitic  Pelvis. 

4.  Pseudo-osteomalacic  Rhachitic  Pelvis. — This  variety  is  a  manifestation 
of  the  severest  forms  of  rhachitis,  and  affords  examples  of  the  most  marked 


Fig.  521. — Pseudo-osteomalacic  Pelvis  (Naegele). 

degrees  of  contraction.     In  such  cases,  as  the  name  implies,  the  pelvis 
resembles  one  deformed  by  osteomalacia,  the  sacrum  and  lateral  walls  ap- 


608 


OBSTETRICS 


proaching  one  another  so  as  to  give  rise  to  a  very  small  triangular  supe- 
rior strait,  the  contraction  also  extending  to  other  portions  of  the  pelvic 
cavity. 

This  form  of  pelvis  was  first  -described  by  Srnellie,  who  gave  an  illus- 
tration of  it  in  his  anatomical  plates.  More  particular  attention  was 
directed  to  it  by  Stein,  and  especially  by  JSTaegele.  It  is  not  of  frequent 
occurrence,  though  Fasbender  in  1878  was  able  to  collect  40  cases  from  the 
literature,  not  a  few  of  which  occurred  in  young  children. 

Mode  of  Production  of  Deformity  in  Rliachitic  Pelves. — We  have  already 
considered  the  part  played  in  the  transformation  of  the  foetal  into  the  adult 
pelvis  by  the  action  of  the  body  weight  and  the  upward  and  inward  force 
exerted  by  the  femora.  Abnormalities  and  variations  in  the  mode  of  action 
of  these  forces  also  serve  to  explain  the  way  in  which  most  of  the  character- 
istic rhachitic  deformities  are  produced. 

These  views  were  developed  in  great  part  by  Litzmann,  and  have  ob- 
tained almost  general  acceptance,  although  Fehling,  Freund,  Kehrer,  and 
others  take  exception  to  them. 

In  the  acute  stages  of  rhachitis  the  young  child  is  unable  to  walk,  and 
spends  its  time  in  a  sitting  or  reclining  position,  in  which  the  upward  and 


Fig.  522.  Fig.  523. 

Figs.  522,  523. — Diagrams  showing  Changes  in  Shape  in  Ehachitic  and  Osteomalacic  Pelves 

(Schroeder). 

inward  force  exerted  by  the  femora  is  in  abeyance.  Consequently,  when 
it  sits  up,  the  bjxly  weight  is  the  only  force  which  comes  into  play,  and  on 
being  transmitted  from  the  vertebral  column  to  the  sacrum,  it  is  resolved 
into  two  forces — one  directed  downward  and  the  other  forward.  As  a 
result,  the  sacrum  rotates  about  its  transverse  axis,  the  promontory  being 
pressed  forward  and  downward,  while  the  remainder  of  the  bone  moves 
in  the  opposite  "direction  and  tends  to  assume  a  more  or  less  horizontal 
position.  The  extreme  upAvard  dislocation  of  its  lower  end  is  resisted  by 
the  traction  exerted  upon  it  and  the  coccyx  by  the  strong  sacro-sciatic 
ligaments,  and  consequently  the  softened  bone  becomes  sharply  flexed  at 
its  lower  portion,  whereby  its  vertical  concavity  is  accentuated.  At  the 
same  time,  owing  to  the  softened  condition  ~of~The  sacrum  and  fhe  imper- 
fect union  between  the  bodies  and  alas  of  its  vertebra?,  the  former  are 
pushed  out  beyond  the  latter,  thus  converting  its  normal  lateral  concavity 
into  a  corn 


MODE  OF    PRODUCTION   OF   RHACHITIC  PELVES  609 

As  the  promontory  is  displaced  forward  and  downward  under  the  influ- 
ence of  the  body  weight,  the  posterior  surface  of  the  sacrum  recedes  from 
the  superior  posterior  spines  of  the  ilium,  thus  subjecting  the  strong  iljo- 
sacral   Ligaments  to  marked   tension.     As  a  resull   the  spines  are  drawn 

nearer_io  the  middle  line,  while  at  the  same  time  the  anterior  porj  ions  of 
the  iliac  bones  flare  min  thus  accounting  for  the  changed  position  of  the 
anterior  superior  spines.  This  movement  is  resisted  by  the  cohesive  force 
exerted  by  the  anterior  pel  vie  wall,  and  as  a  consequence  the  softened 
hones  bend  just  in  fronl  of  the  sacro-iliac  synchondrosis^  so  that  the  ilio- 
pectinea]  line  on  either  side,  instead  of  following  a  gentle  curve,  becomes 
sharply  hent  at   that   point. 

Coincident  with  these  changes,  the  positions  of  the  acetabula  become 
altered,  being  situated  upon  the  anterior,  instead  of  upon  the  lateral  walls 
of  the  pelvis.  As  a  resuit,  when  the  child  begins  to  walk  the  forces  exerted 
by  the  femora  also  add  to  the  flattening  of  the  superior  strait.  On  the 
other  hand,  owing  to  the  previous  non-use  of  the  lower  extremities,  these 
last  forces  have  not  been  called  into  play  early  enough  to  counteract  the 
widening  of  the  pelvis  as  a  result  of  prolonged  sitting,  and  consequently 

the  ischial  tuberosities  become  flared  out. 

.    i  —      i  ■ 

The  same  factors  are  concerned  in  the  production  of  the  generally  con- 
tracted rhachitic  pelvis,  its  small  size  being  due  either  to  atrophy  following 
the  rhachitis,  or  to  the  effect  of  the  disease  upon  a  pelvis  already  abnor- 
mally, small 

The  pseudo-ostcomalacic  form  results  when  the  rhachitic  softening  of 
the  bones  is  very  markedarid  the_child  persists  in  walking.  Under  such 
circumstances  not  only  are  the  characteristic  changes  in  the  sacrum  and 
iliac  crests  produced,  but  at  the  same  time  the  anterior  and  lateral  por- 
tions of  the  pelvis  are  pushed  in  towards  the  sacrum,  the  pelvic  cavity  be- 
coming almost  obliterated. 

As  has  already  been  said,  these  views  have  not  been  universally  accepted, 
Fehling  believing  that  the  characteristic  form  of  the  pelvis  may  result 
in  utero,  before  these  factors  can  come  into  play.  In  not  a  few  cases  of 
foetal  pelvic  deformity  the  embryo  has  suffered  from  so-called  foetal  rhachi- 
tis, which  has  been  designated  as  achon droplas ia  __ and  clinjuh-odifstrophia^ 
fcetalis  by  Porak  and  Kaufmann  respectively,  both  of  whom,  however,  have 
shown  that  it  differs  radically  from  rhachitis.  They  agree,  therefore,  that 
deformities  resulting  from  this  process  cannot  be  compared  with  those 
resulting  from  true  rhachitis  (Fig.  544). 

Freund  has  attempted  to  show  that  in  view  of  the  peculiar  nature  of 
the  sacro-iliac  joints  the  sacrum  cannot  rotate  about  its  transverse  axis. 
His  description  of  these  structures,  however,  appears  to  have  been  based 
in  great  part  upon  conditions  observed  in  adult  life,  and  he  seems  to  have 
lost  sight  of  the  fact  that  articular  surfaces  in  early  life  are  almost  entirely 
cartilaginous,  and  thus  readily  permit  of  motion  in  any  direction. 

Kehrer  believes  that  the  action  of  certain  groups  of  muscles  plays  a 
most  important  part  in  the  production  of  abnormal  pelves.  No  doubt  this 
is  true  to  a  certain  extent,  but  it  is  hardly  probable  that  it  is  the  only 
factor  concerned. 


610  OBSTETRICS 

Diagnosis  of  Rhachitic  Pelves. — Important  information  as  to  the  presence 
of  rhachitis  may  be  elicited  by  the  inspection  and  examination  of  the  patient 
when  characteristic  deformities  may  be  noted  about  the  head,  vertebral  col- 
umn, and  lower  extremities.  In  not  a  few  cases,  the  thickened  epiphyses 
at  the  costal  margins — the  so-called  rhachiik  rosary — may  "also  serve  to  call 
attention  to  the  existence  of  the  disease. 

A  decidedly  pendulous  abdomen  in  primiparous  women  is  always  sug- 
gestive of  marked  disproportion  between  the  size  of  the  head  and  the  pelvis, 
and  should  always  suggest  a  search  for  rhachitic  changes. 

The  age  at  which  the  patient  first  learned  to  walk  is  also  of  consider- 
able importance,  as  it  is  well  known  that  children  suffering  from  rhachitis 
are  usually  backward  in  this  respect.  Again,  when  the  disease  appears  after 
the  first  year  of  life,  the  child  usually  ceases  to  walk  during  its  acute  stages, 
and  has  to  learn  again  at  a  later  period. 

Accurate  information  concerning  the  pelvis,  however,  can  be  obtained 
only  by  pelvimetry.  On  external  mensuration  the  distances  between  the 
spines  and  crests  of  the  ilium  no  longer  show  their  normal  relations,  the 
former  approaching  and  not  infrequently  exceeding  the  latter  in  length. 
Normally,  there  is  a  difference  of  2.5  to  3  centimetres  between  the  two,  and 
whenever  this  becomes  reduced  to  1  centimetre  or  less,  rhachitis  should  be 
suspected.  The  distance  between  the  trochanters  will  be  normal  or  not, 
according  as  one  has  to  deal  with  a  flat  or  generally  contracted  rhachitic 
pelvis.  Baudelocque's  diameter  is  always  considerably  shortened.  At  the 
same  time  Michealis's  rhomboicMoses  its  regular  outlines,  and  in  marked 
cases,  owing  to  the  sinking  downward  and  forward  of  the  sacrum,  becomes 
converted  into  a  triangular  area. 

Still  more  definite  information  may  be  gained  by  internal  pelvimetry. 
The  diagonal  conjugate  is  always  shortened.  The  anterior  surface  of  the 
sacrum  is  mucli  more  readily  accessible  to  the  p^nminijig  fingers,  and  on 
careful  palpation  its  upper  portion  is  found  to  be  flatter  than  usual,  while  its 
lower  portion  is  sharply  bent  forward.  Moreover,  owing  to  the  prominence 
of  the  vertebral  bodies,  the  sacrum  is  found  to  be  convex  from  side  to  side, 
instead  of  concave,  as  normally.  At  the  same  time  the  pelvic  outlet  ap- 
pears to  be  widened. 


?he  flat  rhachitic  pelvis  is  ordinarily  diagnosed  when  the  transverse 
external  measurements  show  but  slight  diminution,  whereas  in  the  generally 
contracted  variety  they  measure  considerably  less  than  normal.  The  gen- 
erally and  equally  contracted  variety  is  rarely  diagnosed  during  life,  while 
the  characteristic  deformity  of  the  pseudo-osteomalacic  form  will  be  recog- 
nised on  internal  examination,  and  the  decision  as  to  whether  it  is  due  to 
rhachitis  or  osteomalacia  will  be  determined  by  the  history  of  the  patient. 

Osteomalacic  Pelves. — Inasmuch  as  osteomalacia  gives  rise  to  the  most 
marked  pelvic  deformities  with  which  we  are  familiar,  it  was  only  natural 
that  the  attention  of  obstetricians  should  have  been  directed  to  it  at  an  early 
date.  Cooper  performed  Cesarean  section  for  this  condition  in  1768,  but 
for  the  main  pioneer  work  we  are  indebted  to  Stein,  Kilian,  and  Litzmann. 

Nature  and  Clinical  History  of  Osteomalacia. — Osteomalacia,  halistere- 
sis,  molliii£s  ossium  or  malacosteon  disease,  is  a  chronic  inflammatory  dis- 


PATIIOLOUY    OF    OSTKOMALACIA  01  1 

case  of  the  bones,  which  become  soft,  yielding,  and  occasionally  brittle,  and 
consequently  undergo  marked  changes  in  shape  as  the  result  of  the  action 
of  ilif  various  mechanical  forces  to  \\  hicb  I  hey  are  subjected. 

The  disease  is  one  of  adulj  life,  and  is  very  rarely  me1  with  in  children. 
It  oeeui's  far  more'  frequently  in  women  than  in  men,  especially  during 
pregnancy  or  the  puer] )  e  i  •  i  u  i  u .  Litzniann.  in  l.siil,  eolleetod  131  cases  from 
the  literature,  85  of  which  were  in  pregnant  or  puerperal  women,  35  in 
non-pregnant  women, and  11  in  men.  Since  that  time  the  number  of  cases 
in  women  has  markedly  increased,  whereas  in  1900  Ilahn  was  able  to  add 
only  .'!1  additional  instances  in  males. 

The  disease  may  oceur  in  any  part  of  the  world,  but  is  especially  f  re- 1 
quent.  and  may  even  be  said  to  he  endemic,  in  certain  localities,  notably! 
in  the  Rhine  Valley,  the  Ergolz  Valley  in  Switzerland,  the  Olona  Valley  | 
and  Calabria  in  Italy,  and  in  the  city  of  Vienna.     It  is  very  rarely  ob- 
served in  this  country,  England,  or  France,  Dock  having  been  able  to  collect 
only  Id  cases  in  America  up  to  1896.    Tarnier,  in  his  large  experience,  en- 
countered only  3  cases  in  Paris,  Hirst  saw  3  in  Philadelphia,  and  up  to  the 
present  time  3  have  come  under  my  observation  in  Baltimore. 

As  yet  no  satisfactory  explanation  for  its  endemic  occurrence  has  been 
adduced,  but  it  seems  to  be  intimately  connected  with  unsanitary  surround-^ 
ings  and  inferior  food.  This  was  strikingly  illustrated  bythe  experience 
of  Winckel,  Sr.,  in  Gummersbach  in  Germany,  and  of  Hoebecke  in  Sotte- 
gem  in  Holland.  The  former  performed  13  and  the  latter  1-1  Cesarean 
sections  upon  osteomalacic  patients  prior  to  18-10.  Since  that  time  improve- 
ment in  the  hygienic  conditions  of  both  villages,  together  with  more  healthy 
occupation  for  their  inhabitants,  has  led  to  an  almost  total  disappearance 
of  the  disease. 

Osteomalacia  may  affect  any  portion  of  the  skeleton,  but  seems  to 
select  more  particularly  the  pelvis^  vertebra^,  and  ribs.  'The  fresh  bones 
are  yellowish  or  yellowish-brown  in  appearance,  and  very  soft  andjiritile.. 
In  advanced  cases  their  consistence  is  that  of  leather  or  wax,  so  that  they 
can  readily  be  cut  with  a  knife.  In  the  later  stages  of  the  disease  the 
spongy  bones  present  a  markedly  areolated  armearance  on  section,  and  in 
some  instances  are  so  rarefied  that  only  the  outer  layers  remain  intact.  At 
the  same  time  they  become  much  lighter,  the  specific  gravity  being  fre- 
quently reduced  by  one  half. 

Under  the  microscope  the  marrow  spaces  are  found  to  be  greatly  en- 
larged, and  there  is  a  marked  increase  in  vascularity.  The  most  important 
change,  however,  consists  in  the  substitution  of  osteoid  tissue  in  place  of 
the  true  bone  surrounding  the  Haversian  canals. 

All  of  the  earlier  writers  upon  the  subject  considered  that  the  changes 
in  the  bone  resulted  from  decalcification,  which  was  due  to  the  presence  of 
lactic  or  a  related  acid  in  the  circulating  blood.  But  after  the  correctness 
of  this  view  had  been  denied  by  Virchow  in  1S52,  the  writers  upon  the 
subject  have  been  divided  into  two  camps:  the  gne  claiming  that  the  essen- 
tial feature  of  the  disease  is  decalcification,  and  the  other,  a  disturbance  in 
the  relation  between  resorption  and  deposition,  by  which  osteoid  instead 
of  osseous  tissue  is  formed.  Full  details  of  this  discussion  are  to  be  found 
40 


612 


OBSTETRICS 


in  the  writings  of  Gelpke,  Kibbert,  Winckel,  and  Laufer,  in  which  the 
entire  subject  is  carefully  considered. 

One  of  the  most  important  contributions  to  the  subject  was  made  by 
Fehling  in  1888,  who  advanced  the  theory  that  the  disease  was  a  tropho- 


Fig.  525 


Fig.  526. 


Figs.  524-526. — Osteomalacic  Pelvis. 


neurosis  of  ovarian  origin.  He  believed  that  characteristic  changes  could 
be  made  out  in  the  ovaries,  and  that  these  gave  rise  to  reflex_  stimulation 
of  the  vasodilators  supplying  the  bones.  Although  this  theory  serves  to 
explain  the  brilliant  results  following  castrajkxa.  in  this  disease,  the  various 
authorities  are  not  yet  agreed  concerning  the  changes  in  the  ovaries,  and 
Bulius,  in  1898,  stated  that  they  were  not  characteristic. 

More  important,  from  a  practical  standpoint,  is  the  clinical  history  of  the 
affection.  In  its  earliest  stages  it  is  characterized  by  peculiar  muscularjml- 
sies,  which  more  especially  affect  the  ilio-psoas,  and  which  are  often  accom- 
panied by  contractures  of  the  abductor  muscleS  of  the  thigh  and  increased 
patellar  reflexesY  A  little  later  rheumatoid  pains  make  their  appearance 
in  various  portions  of  the  body,  and  at  the  same  time  the  pelvis,  ribs,  and 
vertebral  column  become  very  sensitive  upon  pressure.  As  the  disease  ad- 
vances still  further  and  the  bones  become  softer,  various  deformities  appear, 
which  are  particularly  marked  in  the  vertebral  column  and  pelvis. 


OSTEOMALACIC    1'KI.VIS 


613 


The  history  of  osteomalacic  patients  is  usually  of  this  character:  The 

woman  has  had  one  or  more  gonna]  labours.     During  the  nexl   pregnancy 

she~"i'oni|>lains  ol"  muscular  symptoms  and  rheumatoid  pains,  and  greater 
difficulty  is  experience3  ai  the  time  ol  labour.  The  same  symptoms  recur 
with  added  intensity  in  the  succeeding  pregnancy,  and  the  lajjour  is  still 
more  difficult,  probably  reojiiring  craniotomy.  In  the  succeeding  preg- 
nancy the  rheumatoid  pains  become  so  intense  and  locomotion  is  inter- 
fered with  to  "such  an  extent  that  for  the  last  months  the  patient  is  obliged 
to  take  to  her  bed.  This  labour  also  generally  requires  craniotomy  or 
Cesarean  section.  After  its  termination  the  pains  disappear,  and  when 
the  patient  is  able  to  get  about  again  she  notices  that  she  has  become  some 
indies  shorter  than  previously^  the  diminution  in  stature  being  sometimes 
associated  with  kyphotic  changes^  in  the  vertebral  column. 

To  sum  up.  a  history  of  rheumatoid  pains  and  difficult  locomotion  re-| 
quiring  rest  in  bed  during  pregnancy,  associated  with  a  decrease  in  height, 
is  almost  pathognomonic  of  osteomalacia. 

Changes  in  The  Shape  of  the  Pelvis. — The  extent  of  the  deformity  result- 
ing from  osteomalacia  depends  entirely  upon  the  degree  of  softening  which 
the  various  pelvic  bones  have  undergone.  According  to  Kehrer,  in  the 
early  stages  of  the  disease  the  pelvis  is  simply  flattened  as  the  result  of 
the  forcing  downward  and  forward  of  the  promontory  of  the  sacrum.  At 
the  same  time  the  bodies  of  the  vertebra;  are  pushed  out  and  beyond  the  alas, 
and  its  lower  extremity  becomes  markedly  curved  inward,  the  changes  being 
usually  much  more  pronounced  than  in  the  rhachitic  pelvis. 

In  the  later  stages  of  the  disease,  when  the  bones  have  become  very 
soft,  the  pelvis  takes  on  a  characteristic  compressed  appearance.  The  body 
weight  presses  the  promontory  still  further  downward  and  forward,  while 
the  upward  and  inward  forces  exerted  by  tlieiemoTa  puslrtlteTateral  walls 


Fig.  527. — Osteomalacic  Pelvis,  Inferior  Strait. 

of  the  pelvis  inward,  until  in  very  marked  cases  the  superior  strait  becomes 
almost  entirely  obliterated.  At  the  same  time  the  ischio-pubic  rami  are 
approximated,  and  the  pubic  arch  is  converted  into  a  narrow  slit  into  which 
it  is  sometimes  impossible  to  insinuate  the  fingers.     The  pubic  rami  are 


614  OBSTETRICS 

pushed  markedly  forward,  giving  rise  to  a  beak-like  protuberance  upon  the 
anterior  Avail  of  the  pelvis.  Coincident  with  these  changes,  there  is  a 
marked  diminution  in  the  size  of  the  pelvic  cavity  and  of  the  inferior  strait, 
though  m  not  a  few  cases,  owing  to  constant  sitting  upon  the  softened 
bones,  the  tubera  ischii  are  considerably  flared  out.  In  advanced  cases  the 
pelvis  is  very  much  deformed,  and  may  present  any  one  of  an  almost  infinite 
variety  of  bizarre  shapes. 

Diagnosis. — The  diagnosis  is  readily  made,  as  careful  inquiry  will  usu- 
ally elicit  the  characteristic  clinical  history  of  the  disease;  while  examina- 
tion of  the  pelvis  will  show  that  it  is  markedly  compressed  in  all  directions, 
and  the  pathognomonic  changes  in  the  pubic  arch  can  hardly  escape  detec- 
tion. Indeed,  the  only  form  of  pelvis  with  which  it  might  be  confounded 
is  the  very  rare  transversely  contracted  Eobert  pelvis,  but  the  absence  of 
the  characteristic  clinical  history  and  the  lack  of  antero-posterior  shorten- 
ing in  the  latter  will  usually  enable  one  to  differentiate  between  them. 


LITERATURE 

Ahlfeld.     Die  Diagnose  des  einfach  platten  Beekens  an  der  Lebenden.     Zeitschr.  f.  Geb. 

u.  Gyn.,  1895,  xxxii,  356-367. 
Betschler.     Annalen  der  klin.  Anstalten,  Breslau,  1832,  i,  24-60,  ii,  31. 
Bulius.     Osteomalaeie  u.  Eierstock.     Hegar's  Beitrage,  1898.  i,  138. 
Deventer.    Neues  Hebammenlicht,  III.  Ann.,  Jena,  1728,  199. 

Dock.     Osteomalacia,  with  a  New  Case.     Amer.  Jour.  Med.  Sciences,  1895,  cix,  499-516. 
Fasbexder.     Ueber  das  pseudo-  und  das  rachitisch-osteomalacische  Becken.     Zeitschr.  f. 

Geb.  u.  Gyn.,  1878,  ii,  332-345. 
Fehlixg.    Die  Entstehung  der  rachitischen  Beckenform.   Archiv  f.  Gyn.,  1877,  xi,  173-183. 
Ueber  Kastration  bei  Osteomalaeie.     Verh.  d.  deutschen  Gesellsch.  f.  Gyn.,  1888,  ii, 

311-318. 
Preuxd.     Ueber  das  sogenannte  kyphotische  Becken.     Gyn.  Klinik,  1885,  1-134. 
Gelpke.     Die  Osteomalaeie  im  Ergolzthale.     Basel,  1891. 
Hahx.     Ueber  Osteomalaeie  beim  Manne.      Zusammenfassendes  Referat:  Centralbl.  f. 

die  Grenzgebiete  der  Med.  u.  Chir..  1900.  iii. 
Hirst.     A  Text-Book  of  Obstetrics.     Third  edition,  465.     Philadelphia,  1901. 
Kassowitz.     Die  normale  Ossification  und  die  Erkrankungen  bei  Rachitis  und  hereditarer 

Syphilis.     Wien,  1882. 
Kaufmaxx.     Untersuchungen  liber  die  sogenannte  fotale  Rachitis.     Berlin,  1892. 
Kehrer.     Zur  Entwickelungsgeschichte  des  rachitischen  Beekens.     Archiv  f.  Gyn.,  1873, 

i,  55-99. 
Pelvis  plana  osteomalacica.     Centralbl.  f.  Gyn.,  1901,  986-990. 
Kiliax.     Beitrage  zu  einer  genauen   Kenntniss  der  allgemeinen   Knochenerweichung 

der  Frauen.     Bonn,  1829. 
Das  halisteretische  Becken.     Bonn,  1857. 
Latzo.     Beitrage  zur  Diagnose  und  Therapie  der  Osteomalaeie.     Monatsschr.  f.  Geb.  u. 

Gyn.,  1897,  vi,  571-608. 
Laufer.    Zur  Path.  u.  Therapie  der  Osteomalaeie  des  Weibes.     Centralbl.  f.  die  Grenz- 
gebiete der  Med.  u.  Chir.,  1900,  iii,  Xr.  1. 
Litzmaxn.     Die  Formen  des  Beekens,  nebst  einem  Anhange  iiber  Osteomalacic     Berlin, 

1861. 
Die  Geburt  bei  en  gem  Becken.     Leipzig,  1884,  36. 


PELVIC    ANOMALIES   DUE  TO   ABNORMAL   MALLEABILITY        015 

Mi' m.  w. is.     Das  enge  Becken,  Leipzig,  1851. 

Muller.    Zur  Frequenz  and  Aetiologie  ties  allgemein  verengten  Beckens.    Archiv  f. 

Gyn.,  1880,  xvi,  L55-174. 
Naegele.     l>a- -'liraL:  v.  rciigte  Bee-ken.     Mainz,  1839. 

Porak.     Dc  l'achondroplasie.    Nouvelles  Archives  d'Obst.  et  de  Gyn.,  December,  1889. 
Ribbert.    Die  Osteomalacic     Bibliotbeca  Medica. 

Si  n  i.  m.imi  ak  k.     Oeber  path.  Beckenformen  lnim  Fotus.    Archiv  f.  Gyn.,  1882,  xx,  43o— !•>!. 
Smellie.     Anatomical  Tables,  etc.     Plate  III.  new  edition,  Edinburgh,  17^7. 
Spillmann.     Le  Rachitisme.     These  de  Nancy,  1900. 
Stein.     Kleine  Werke  zur  prakt.  Geburtshulfe,  1798,  283-340,  dazu,  Taf.  X. 

Die  Lehranstalt  der  Geburtshulfe  zu  Bonn,  I.  Heft,  Elberfeld,  1823. 
Tarxier  et  Bldix.     Traite  de  l'art  des  accouehements,  1898,  iii. 
Virchow.     Archiv  f.  path.  Anat.  u.  Physiol.,  1852,  iv, 
Williams,  J.  Wuitridge.     Pelvic  Indications  for  the  Performance  of  Cesarean  Section. 

American  Medicine,  1901,  ii,  483. 
Winckel.     Behandlung  der  Osteomalaeie.     Pentzoldt  u.  Stintzing.     Handbuch  der  spec. 

Therapie.  1896,  Bd.  v,  Abth.  vii,  214-242. 
Zweifel.     Aetiologie,  Prophylaxis  und  Therapie  der  Rachitis.     Leipzig,  1900. 


CHAPTEE    XXXV 

PELVIC  ANOMALIES  DUE   TO   ABNORMAL  MALLEABILITY  OF 
THE  PELVIC  BONES  (Continued) 

EFFECT    UPON    THE    COURSE    OF    PREGNANCY  AND    THE 
MECHANISM    OF    LABOUR— TREATMENT 

Maeked  degrees  of  pelvic  deformity  exert  a  pronounced  influence  upon 
the  course  of  pregnancy  as  well  as  upon  the  mechanism  of  labour.  Indeed, 
to  he  unaccompanied  by  more  or  less  untoward  effects  the  contraction  must 
be  minimal. 

Effect  of  Contracted  Pelves  upon  the  Course  of  Pregnancy. — The  Posi- 
tion of  the  Uterus. — In  the  early  months  of  pregnancy  a  minor  grade  of 
pelvic  malformation  may  exert  little  or  no  influence  upon  the  position  of 
the  uterus,  but  when  present  in  any  marked  degree  it  may  interfere  with 
the  normal  rising  up  of  that  organ,  particularly  if  the  promontory  of  the 
sacrum  nroi'""1'  j  the  superior  strait  as  markedly  to  overhang  the 

pelvic  c  ~oii  cases  the  fundus  impinges  upon  the  anterior  sur- 

face of  th\  a'um,  and  as  the  uterus  increases  in  size  it  assumes  a  position 
of  more  or  less  pronounced  retroflexion,  which  later  may  give  rise  to 
characteristic  symptoms  of  incarceration. 

When  the  deformity  is  sufficient  to  interfere  with  the  descent  of  the 
presenting  part  into  the  pelvis,  marked  abnormalities  in  the  position  of 
the  uterus  are  observed  in  the  later  months  of  pregnancy.  Under  such  cir- 
cumstances, particularly  in  primiparse,  the  fundus  occupies  a  higher  posi- 
tion than  usual,  and  serious  respiratory  and  circulatory  disturbances  often 
result.  At  the  same  time,  owing  to  the  fact  that  the  lower  portion  of  the 
uterus  is  not  fixed  by  the  engaged  head,  the  entire  organ  is  much  more 
freely  movable  than  usual. 

More  important,  however,  is  the  sharply  anteflexed  position  which  the 
uterus  assumes  as  a  consequence  of  serious  disproportion  in  size  between  the 
head  and  the  pelvis.  This  is  emphasized  more  particularly  in  small  women 
suffering  from  marked  lumbar  lordosis,  in  whom  the  capacity  of  the  abdo- 
men is  so  greatly  diminished  that  the  growing  uterus  seeks  to  gain  room 
by  pushing  forward  the  anterior  abdominal  walls.  The  presence  of  a  pendu- 
lous abdomen  is  a  sign  of  considerable  importance  in  primiparous  women, 
and  should  always  cause  one  to  suspect  the  existence  of  marked  pelvic  de- 
formity. The  converse,  however,  by  no  means  always  holds  good,  and  its 
616 


EFFECT  OF  PELVIC   ANOMALIES    I  T"\   COURSE  OF    PREGNANCY     617 

absence  does  not  necessarily  indicate  that  no  disproportion  exists.  More- 
over, a  pendulous  abdomen  is  often  observed  in  multiparous  women,  and 
may  have  do  greal  significance,  being  generally  due  to  a  loss  of  tonicity  of 
the  uterine  and  abdominal  walls  as  a  result  of  previous  pregnancies. 

Position  and  Presentation  of  Foetus. — A  contracted  pelvis  plays  an  impor- 
lani  pari  in  the  production  of  abnormal  presentations.  In  primiparous 
women,  when  the  pelvis  is  normal,  the  presenting  part,  as  a  rule,  descends 
into  the  pelvic  cavity  during  the  last  six  weeks  of  pregnancy;  but  when  the 
superior  -trail  is  considerably  contracted  this  does  not  occur  until  after 
the  onset  of  labour,  and  sometimes  not  at  all.  Vertex  presentations  still 
predominate;  bu1  since  the  head  floats  freely  above  the  superior  strait,  or 
rests  upon  one  of  the  iliac  fossae,  very  slight  influences  may  cause  the  foetus 
to  assume  other  positions.  According  to  Michealis,  vertex  presentations 
are  rarer  by  10  per  cent  in  contracted  than  in  normal  pelves;  while  face,, 
breech,  and  transverse  presentations  occur  2  or  3  times,  and  prolapse  of  the 
cord  and  the  extremities  4  to  6  times  more  frequently. 

Abnormal  presentations  increase  in  frequency  with  the  degree  of  con- 
traction, as  is  shown  by  the  following  figures  of  Michealis,  Litzmann,  and 
Schwartz: 

Conjugata  vera  9.5  —  8.5  cm.,  93.1$  vertex  presentations. 

«     8.4  -  7.5    "     83.8#      " 

"     7.4  cm.  or  less,  64. 7#      "  " 

Tarnier,  in  1,030  cases  of  labour  complicated  by  contracted  pelves,  ob- 
served 882  vertex  (85.13  per  cent  instead  of  96  per  cent),  ",  2  breech  (7  per 
cent  instead  of  3  per  cent),  32  face  (3  per  cent  instead  of  0.6  per  cent),  and 
44  transverse  presentations  (4.2  per  cent  insttc,  ",p.n+) 

As  has  been  seen,  abnormal  presentations  ocetii  entlv  in 

multiparous  than  in  primiparous  women  even  under  favoura.  conditions, 
and,  as  might  be  expected,  they  become  still  more  common  when  the  pelvis 
is  contracted.  Thus,  Schauta  estimated  that  they  are  3  times  more  fre- 
quent in  the  fifth  than  in  the  first  pregnancy. 

Face  and  transverse  presentations  possess  a  peculiar  significance  in 
primiparous  women,  and  their  occurrence  is  nearly  always  associated  with 
marked  disproportion  between  the  size  of  the  head  and  the  pelvis,  so  that 
whenever  either  variety  is  encountered  one  can  feel  certain  that  the  head 
is  abnormally  large  or  the  pelvis  abnormally  small. 

Size  of  Feet  us. — La  Torre,  Pinard.  and  others  have  stated  that  the  chil- 
dren of  women  with  abnormal  pelves  usually  attain  a  larger  size  than  usual. 
Pinard  attributes  this  to  the  fact  that  in  such  cases  the  head  does  not  be- 
come engaged  during  the  last  few  weeks  of  pregnancy,  and  therefore  cannot 
press  upon  the  lower  uterine  segment,  thus  doing  away  with  one  of  the 
factors  predisposing  to  the  premature  termination  of  pregnancy.  "Wilcke, 
after  careful  study,  has  concluded  that  such  is  not  the  case,  and  that  the 
children,  under  such  circumstances,  are  generallv  slightly  smaller  than 
usual.  This  is  particularly  the  case  when  the  pelvis  is  generally  contracted, 
as  such  women  are  usually  under-sized  and  would  naturally  give  birth  to 
smaller  children  than  would  larger  and  better  formed  individuals. 


618  OBSTETRICS 

Mechanism  of  Labour  in  Simple  Flat  and  Flat  Rhachitic  Pelves. — The 

possibility  of  the  occurrence  of  spontaneous  labour  in  flat  pelves  depends 
primarily  upon  the  degree  of  contraction,  and,  when  this  is  not  excessive, 
upon  the  following  additional  factors:  the  size,  compressibility,  and  malle- 
ability of  the  foetal  head,  and  the  character  of  the  expulsive  forces.  The 
measurements  of  the  pelvis  can  be  estimated  with  tolerable  accuracy,  but 
there  are  no  satisfactory  methods  of  determining  in  advance  the  size  and 
other  properties  of  the  head,  and  not  until  labour  has  come  on  can  one  tell 
at  all  approximately  what  the  uterus  can  do. 

In  our  287  cases  of  labour  in  contracted  pelves,  spontaneous  delivery 
occurred  in  199  (71.58  per  cent),  and  became  less  frequent  the  more  maiked 
the  pelvic  deformity.     Thus,  when  the  conjugata  vera  measured 

10  —  9  cm.,  spontaneous  delivery  occurred  in  77.28$. 
8.9-8    "  "  "  "  61.54$. 

7.9-7   "  "  "  "  334$. 

6.9  cm.  or  less,      "  "  "  none. 

Even  when  the  child  is  born  spontaneously  and  without  any  undue  delay, 
certain  characteristic  abnormalities  can  be  observed  in  the  mechanism  of 
labour  by  which  the  experienced  obstetrician  is  enabled  to  diagnose  the 
presence  of  a  flat  pelvis  without  resorting  to  pelvimetry. 

Inasmuch  as  in  the  varieties  of  pelves  under  consideration,  the  contrac- 
tion is  practically  limited  to  the  anterior  posterior  diameter  of  the  superior 
strait,  while  the  transverse  diameter  remains  unchanged,  or  may  even  be 
slightly  enlarged,  it  is  evident  that  the  obstacle  to  the  passage  of  the  child's 
head  is  offered  by  the  shortened  conjugata  vera;  and  when  this  measures 
less  than  9  or  9.5  centimetres  it  becomes  out  of  the  question  for  the  bipari- 
etal  diameter  of  the  head  to  pass  through  it,  unless  it  undergoes  some  dimi- 
nution in  size.  Accordingly,  when  engagement  occurs,  the  head  slips  to 
one  side  so  as  to  bring  the  shorter  bitemporal  diameter  in  relation  with  the 
conjugata  vera.  As  a  result,  the  long  arm  of  the  head  lever  becomes  dis- 
placed to  the  side  of  the  occiput,  so  that  the  anterior  portion  of  the  head 
descends  under  the  influence  of  the  uterine  contractions,  while  the  occipital 
portion  rises  up.  Under  these  conditions  the  large  fontanelle  is  found  to  be 
readily  accessible  to  the  examining  finger  on  one  side  of  the  pelvis,  while 
the  small  fontanelle  is  reached  with  some  difficulty  on  the  other.  At  the 
same  time,  owing  to  the  fact  that  the  transverse  diameter  of  the  superior 
strait  is  not  shortened,  the  head  tends  to  accommodate  itself  to  it,  so  that 
its  long  axis,  as  indicated  by  the  sagittal  suture,  comes  to  lie  transversely. 

More  characteristic  still  is  the  abnormal  attitude  which  the  head  as- 
sumes when  the  disproportion  between  it  and  the  pelvis  is  at  all  marked, 
so  that  we  have  what  is  known  as  an  anterior  parietal  presentation.  In  this 
the  presenting  part,  which  is  the  anterior  parietal  bone,  occupies  the  supe- 
rior strait  in  such  a  manner  that  the  sagittal  suture  lies  just  in  front  of  the 
promontory.  Under  such  circumstances  the  anterior  shoulder  is  readily 
distinguished  upon  external  palpation.  According  to  the  explanation  gen- 
erally accepted,  this  condition  is  brought  about  by  the  abnormal  relation 
borne  by  the  axis  of  the.  anteflexed  uterus  to  the  plane  of  the  superior 


MECHANISM   OF   LABOUR  IN   PLAT    PELVES 


619 


strait,  as  the  result  of  which  the  posterior  portion  of  the  head  is  pressed 
against  the  promontory  of  the  sacrum,  where  it  becomes  arrested,  while  its 
anterior  portion  is  forced  into  the  pelvis. 

This  presentation  is  simply  an  exaggeration  of  the  so-called  Nacgele's 
obliquity,  and  the  mechanism  of  descent  is  readily  understood  when  we  com- 
pare the  passage  of  the  head  through  the  abnormal  superior  strait  to  the 
mano'iivre  necessary  to  pass. a  stick  of  a  certain  length  through  a  ring  of  a 
somewhat  shorter  diameter.  To  do  so,  one  must  depress  one  end  of  the 
stick  so  as  to  allow  it  to  enter  the  ring  obliquely,  and  after  it  has  nearly 
passed  through  its  other  end  must  likewise  be  lowered. 


Fig.  528. — Showing  Anterior  Parietal 
Presentation. 


Fig.  529. — Showing  the  Passage  of  ax  An- 
terior Parietal  Presentation  through 
the  Superior  Strait. 


In  order  for  descent  of  the  head  to  occur,  the  posterior  parietal  bone 
is  firmly  pressed  against  the  promontory  of  the  sacrum,  while  under  the 
influence  of  the  uterine  contractions  the  anterior  portion  of  the  head  is" 
slowly  forced  down  into  the  pelvis  along  the  posterior  surface  of  the  sym- 
physis pubis;  after  this  is  accomplished  the  posterior  portion  passes  over 
the  promontory  and  enters  the  pelvis,  the  sagittal  suture  at  the  same  time 
moving  forward.  Under  such  circumstances,  when  the  contraction  is 
marked,  considerable  pressure  must  be  exerted  upon  the  posterior  portion 
of  the  head.  Evidence  of  this  is  usually  afforded  after  birth  by  a  more  or 
less  well-defined  curved  depression,  just  behind  the  coronal  suture,  upon 
the  side  of  the  head  which  was  in  contact  with  the  promontory.  After  the 
posterior  parietal  bone  has  passed  the  superior  strait,  all  resistance  has 
been  overcome,  and,  owing  to  the  fact  that  the  lower  portion  of  the  pelvis 
is  often  larger  than  usual,  the  rest  of  the  labour  is  promptly  accomplished. 

In  a  small  number — according  to  Litzmann  about  one  fourth  of  the 
cases — the  reverse  condition — the  posterior  parietal  presentation — is  ob- 
served. The  sagittal  suture  now  lies  almost  in  contact  with  the  symphysis 
pubis,  while  the  posterior  parietal  bone  occupies  the  superior  strait,  and  in 
marked  cases  the  posterior  ear  of  the  child  can  be  felt  just  above  the  prom- 
ontory, so  that  the  condition  is  sometimes  spoken  of  as  an  ear  presentation. 
The  long  axis  of  the  child's  body  forms  an  obtuse  angle  with  its  head,  and 


620 


OBSTETRICS 


upon  palpation  the  anterior  portion  of  the  latter  can  be  felt  as  a  prominent 
tumour  lying  above  the  symphysis. 

In  order  for  the  head  to  enter  the  pelvis,  its  posterior  portion  must 
be  pushed  down  past  the  promontory  of  the  sacrum,  after  which  its  anterior 


Fig.  530.- 


-Showing  Posterior  Parietal 
Presentation. 


Fig.  531. — Showing  the  Passage  of  a  Pos- 
terior Parietal  Presentation  through 
Superior  Strait. 


portion  descends  along  the  symphysis  pubis,  while  at  the  same  time  the 
sagittal  suture  approaches  the  middle  line  of  the  pelvis.  After  this  has 
occurred  labour  takes  place  in  the  usual  manner. 

The  mode  of  production  of  this  abnormality  is  not  definitely  understood, 
although  it  is  observed  most  frequently  when  the  grade  of  contraction  is 
marked,  the  pelvic  inclination  considerably  increased,  and  the  abdomen 
not  pendulous.  The  presentation  is  generally  considered  as  very  unfavour- 
able by  the  Germans,  as  the  line  along  which  the  uterine  contractions 
are  transmitted  is  given  another  direction  at  the  neck  and  is  much  less 
advantageous  than  when  the  spinal  column  and  head  form  a  continuous 
axis.     Tarnier  and  Varnier,  on  the  other  hand,  hold  that  it  occurs  much 

more  frequently 
than  the  anterior 
parietal  presenta- 
tion, and  is  without 
ominous  prognostic 
significance.  In- 
deed;  they  believe 
that  it  is  merely  an 
exaggeration  of  the 
process  observed  in 
the  normal  mechan- 
ism of  labour.  In 
my  experience,  how- 
ever, it  has  occurred 
far  less  frequently  than  the  anterior  parietal  presentation,  although  in 
many  cases  it  has  not  been  associated  with  a  particularly  difficult  labour. 


Fig.  532. — Engagement  of  Head  in  Keniform  Superior  Strait 
(Tarnier). 


MKCIIAXISM   OF   LABOUR    IN   CONTRACTED    PELVES 


621 


When  the  promontory  oi"  the  sacrum  protrudes  into  the  superior  strait 
in  such  a  way  as  to  render  it  reniform  in  outline,  it  is  impossible  for  the 
head  to  assume  its  usual  transverse  position,  and  the  sagittal  suture  must 
occupy  an  oblique  diameter  (Fig.  532). 

In  rare  instances  the  promontory  may  project  so  far  forward  as  to  make 
the  superior  -trait  resemble  the  figure  8.  Under  such  circumstances  only 
one  side  of  it  is  available  for  the  passage  of  the  head,  and  Breisky  has 
designated  the  condition  as  extra-median  engagement.  It  is,  however,  of 
very  rare  occurrence,  and  need  not  be  considered  further. 

When  the  pelvie  contraction  is  complicated  by  the  existence  of  a  face 
presentation,  the  prognosis  becomes  more  dubious,  as  it  is  more  difficult  for 
the  face  than  for  the  vertex  to  pass  the  contracted  superior  strait,  and 
accordingly  the  course  of  labour  is  unduly  prolonged. 

Breech  presentations  likewise  complicate  matters  to  some  extent,  as 
they  are  very  frequently  accompanied  by  prolapse  of  the  cord  or  of  one  or 
more  of  the  extremities,  owing  to  the  imperfect  adaptation  of  the  breech 
to  the  superior  strait.  Under  such  cir- 
cumstances, although  the  prognosis  for 
the  mother  remains  favourable,  the 
child's  life  is  endangered.  This  is 
especially  true  when  the  contraction 
is  marked,  as  considerable  difficulty 
may  be  experienced  in  extracting  the 
after-coming  head,  and  if  this  be  not 
promptly  accomplished  the  child  will 
inevitably  perish. 

The  after-coming  head,  in  passing 
through  the  contracted  superior  strait, 
follows  a  mechanism  analogous  to  that 
observed  in  anterior  parietal  presen- 
tations. In  other  words,  its  posterior 
portion  is  arrested  at  the  promontory,  while  its  anterior  portion  passes  down 
behind  the  symphysis,  after  which  its  posterior  portion  descends. 

Mechanism  of  Labour  in  Generally  Contracted  Flat  and  Generally  Equal- 
ly Contracted  Rhachitic  Pelves. — The  mechanism  of  labour  in  generally 
contracted  flat  pelves  varies  according  to  the  extent  of  the  deformity  and  the 
shape  of  the  pelvis — that  is.  according  as  it  approaches  more  closely  to  the 
flat  or  to  the  generally  contracted  type.  In  the  former  case,  provided  the 
contraction  be  not  too  marked,  the  mechanism  of  labour  will  be  identical 
with  that  just  described  for  flat  pelves,  whereas  in  the  latter  the  head  will 
become  sharply  flexed  and  be  born  by  the  mechanism  which  we  shall  con- 
sider in  detail  when  we  study  the  generally  contracted  or  justo-minor 
pelvis. 

In  the  generally  and  equally  contracted  rhachitic  pelvis  the  mechanism 
corresponds  to  that  observed  in  the  justo-minor  pelvis. 

In  the  pseudo-osteomalacic  forms  the  contraction  is  usually  so  marked 
as  to  preclude  the  possibility  of  the  head  entering  the  superior  strait,  and 
the  child  cannot  be  born  per  vias  naturales. 


Fig.  533. — Showing  Passage  of  After-com- 
ing Head  through  Superior  Strait; 
Darker  Child  Last. 


622  OBSTETRICS 

Course  of  Labour  in  Contracted  Pelves. — When  the  pelvic  deformity  is 
sufficiently  marked  to  prevent  the  head  from  entering  the  superior  strait 
during  the  last  few  weeks  of  pregnancy  or  at  the  onset  of  uterine  con- 
tractions, the  course  of  labour  is  usually  unduly  prolonged.  In  the  first 
stage  this  is  due  to  imperfect  dilatation  of  the  cervix,  and  in  the  second 
:  to  the  time  required  to  so  mould  and  configure  the  head  as  to  render  pos- 
■■  sible  its  entrance  into  the  pelvic  cavity. 

Abnormalities  in  Dilatation  of  Cervix. — Xormally,  dilatation  of  the  cer- 
vix is  brought  about  by  the  unruptured  membranes  acting  as  a  hydrostatic 
wedge,  and  after  their  rupture  by  the  direct  action  of  the  presenting  part. 
In  contracted  pelves,  on  the  other  hand,  when  the  head  is  arrested  at  the 
superior  strait,  the  entire  force  exerted  by  the  uterus  acts  directly  upon 
the  portion  of  membranes  in  contact  with  the  internal  os,  and  consequent- 
ly, as  its  force  is  not  broken  by  the  intervening  head,  as  in  normal  labour, 
premature  rupture  frequently  results,  occurring,  according  to  Litzmann,  in 
26  per  cent  of  the  cases. 

After  rupture  of  the  membranes,  further  dilatation  cannot  take  place 
until  the  presenting  part  is  able  to  exert  a  direct  pressure  irpon  the  cervix, 
and  this  is  out  of  the  question  until  a  long  succession  of  strong  pains  have 
moulded  the  head  sufficiently  to  permit  its  descent.  In  not  a  few  instances, 
I  however,  a  caput  succedaneum  forms  upon  the  most  dependent  portion  of 
the  presenting  part,  and  aids  materially  in  the  dilatation  of  the  cervix. 

Even  after  the  cervix  is  completely  dilated  considerable  delay  may 
occur,  and  it  sometimes  requires  hours  to  mould  the  head  to  the  pelvis; 
but  in  flat  pelves  the  labour  is  promptly  terminated  as  soon  as  the  con- 
tracted superior  strait  is  passed.  In  the  generally  contracted  varieties,  how- 
ever, this  is  not  the  case,  inasmuch  as  the  hindrance  persists  throughout  the 
entire  pelvic  canal. 

Abnormalities  in  Uterine  Contractions. — Not  infrequently  the  course  of 
labour  is  still  further  prolonged  owing  to  faulty  uterine  contractions. 
This  is  rarely  the  case  in  rhachitic  primiparas,  in  whom  the  pains  are  usu- 
ally very  efficient;  but  in  multipara?,  in  whom  previous  difficult  labours 
have  weakened  the  uterine  musculature,  secondary  uterine  inertia  not  infre- 
quently occurs  as  the  result  of  exhaustion. 

In  a  small  number  of  cases  the  uterus,  instead  of  presenting  signs  of  sec- 
ondary inertia,  may  become  tetanically  contracted.  Tbis  is  an  extremely  seri- 
ous condition,  as  it  cannot  lead  to  the  termination  of  labour,  and  at  the  same 
time  markedly  increases  the  danger  of  uterine  rupture.  If  this  complication 
does  not  yield  promptly  to  the  administration  of  sedatives,  it  affords  an  im- 
perative indication  for  the  termination  of  labour  by  one  means  or  another. 

Danger  of  Uterine  Rupture. — Abnormal  conditions  in  the  lower  uterine 
segment  not  infrequently  constitute  a  very  serious  danger,  especially  when 
the  disproportion  between  the  head  and  the  pelvis  is  pronounced. 

Under  such  circumstances,  after  a  prolonged  second  stage,  with  the 
head  still  at  the  superior  strait,  the  lower  uterine  segment  becomes  mark- 
edly stretched,  so  that  the  danger  of  rupture  becomes  imminent.  In  such 
eases,  the  contraction  ring  can  be  felt  as  a  transverse  or  oblique  ridge  ex- 
tending across  the  uterus  a  short  distance  below  the  umbilicus  and  occasion- 


COURSE  OF   LABOUR   IX    CONTRACTED    PELVES  623 

ally  at  its  level,  while  in  not  a  few  instances  its  position  is  clearly  risible. 
Thinning  of  the  Lower  uterine  segmenl  is  part icularly  liable  to  occur  in  the 
generally  contracted  variety  of  rhachitic  pelves,  since  the  lower  end  of 
the  cervix  may  be  caught  between  the  child's  head  and  the  pelvic  brim, 
and  thus  be  prevented  from  retracting,  thereby  facilitating  the  stretching 
of  the  lower  uterine  segment.  Whenever  this  condition  is  noted  prompt 
delivery  is  urgently  indicated;  but  at  the  same  time  great  caution  is 
necessary  on  the  part  of  the  physician  lest  his  manoeuvres  give  rise  to 
traumatic  rupture. 

Production  of  Fistula:. — "When  the  presenting  part  is  firmly  wedged  into 
the  superior  strait,  but  makes  no  advance  for  a  long  time,  portions  of  the 
generative  tract  lying  between  it  and  the  pelvic  wall  may  be  subjected 
to  undue  pressure  for  a  considerable  length  of  time.  As  a  result  the  circu- 
lation is  interfered  with  and  necrosis  follows,  which  may  manifest  itself  a 
few  days  after  labour  by  the  appearance  of  vesico-vaginal,  vesico-cervical, 
or  recto-vaginal  fistula?,  depending  upon  the  part  subjected  to  pressure. 
These  conditions  are  not  to  be  feared  so  long  as  the  membranes  remain 
intact,  but  are  liable  to  follow  a  very  prolonged  second  stage. 

Intra- pa  Hum  Infection. — Infection  is  another  serious  danger  to  which 
the  patient  is  exposed  in  prolonged  labours  complicated  by  contracted 
pelves,  particularly  when  she  is  examined  repeatedly  by  a  physician  who 
does  not  observe  the  most  stringent  aseptic  technique.  The  amniotic  fluid 
may  become  infected  and  give  rise  to  febrile  symptoms  during  labour,  while 
in  not  a  few  cases  the  micro-organisms  may  pass  through  the  foetal  mem- 
branes and  invade  the  uterine  walls,  giving  rise  to  the  characteristic  mani- 
festations of  infection  during  the  puerperium. 

In  other  instances,  gas-producing  bacteria  may  be  introduced  into  the 
uterus,  which  soon  becomes  distended  with  gas  as  a  result  of  their  activity 
— tympanites  uteri  or  physometra.  This  condition  usually  follows  infec- 
tion with  bacillus  aerogenes  capsulatus,  particularly  when  the  child  is  dead. 
It  was  formerly  attributed  to  the  entrance  of  air  into  the  uterus,  but  at 
present  such  an  explanation  must  be  regarded  with  scepticism.  For  fur- 
ther details,  the  reader  is  referred  to  the  chapter  upon  Puerperal  Infection. 

Rupture  of  the  Pelvic  Joints. — In  rare  instances,  particularly  when  the 
pelvis  is  contracted  in  its  lower  portion,  spontaneous  rupture  of  the  sym- 
physis  pubis  or  of  one  or  both  sacro-iliac  joints  has  been  observed.  Such 
cases  have  been  reported  by  Ahlfeld,  Schauta,  Braun-Fernwald,  Rudaux, 
De  Lee,  and  others,  though  in  the  majority  the  injury  is  produced  by  inju- 
dicious methods  of  delivery. 

Effect  of  Labour  upon  the  Child. — So  long  as  the  membranes  remain 
intact  the  child  suffers  but  little  from  the  prolonged  labour;  but  after  their 
rupture  frequent  and  prolonged  uterine  contractions  exert  a  deleterious 
influence  upon  it.  This  is  due  in  great  part  to  interference  with  the  pla- 
cental circulation,  owing  to  which  the  child  receives  imperfectly  aerated 
blood,  which  sooner  or  later  leads  to  manifestations  of  asphyxiation.  Xow 
and  again  premature  separation  of  the  placenta  occurs,  causing  certain 
death  to  the  child. 

After  the  membranes  have  ruptured,  and  particularly  during  the  second 


624 


OBSTETRICS 


stage  of  labour,  prolonged  pressure  exerted  upon  the  head  is  not  without 
influence  upon  the  child,  in  some  cases  leading  to  vagus  stimulation  with 
its  resulting  slow  pulse  and  consequent  gradual  asphyxiation. 

Prolapse  of  the  Cord. — A  much  more  serious  and  frequent  complication 
for  the  child  is  prolapse  of  the  cord,  the  occurrence  of  which  is  facilitated 
by  imperfect  adaptation  between  the  presenting  part  and  the  pelvic  inlet. 
The  condition  exerts  no  influence  upon  the  course  of  labour,  but  in  the 
majority  of  cases  death  of  the  child  results  from  compression  of  the  cord 
between  the  presenting  part  and  the  pelvic  wall,  unless  prompt  delivery 
can  be  accomplished.  This  must  be  regarded  as  one  of  the  most  frequent 
causes  of  foetal  death  in  spontaneous  labour  in  contracted  pelves. 

Changes  in  Scalp  and  Skull. — As  has  already  been  stated,  a  marked  caput 
is  frequently  developed  upon  the  most  dependent  part  of  the  head  in  pro- 
longed labour,  and  allusion  has  been  made  to  the  part  which  it  sometimes 
plays  in  the  dilatation  of  the  cervix.  In  many  instances  it  may  assume 
very  considerable  proportions,  but  is  without  significance  so  far  as  the  life 
of  the  child  is  concerned,  usually  disappearing  within  a  few  days  after 
birth.  When  it  is  well  marked  it  may  lead  to  serious  diagnostic  errors,  as 
it  may  project  well  down  into  the  pelvic  cavity  while  the  head  is  still  above 
the  brim,  so  that  an  inexperienced  physician  may  mistake  it  for  the  head 
and  thus  be  tempted  to  resort  to  ill-timed  operative  measures. 

"When  the  disproportion  between  the  size  of  the  head  and  the  pelvis  is 
considerable,  it  is  apparent  that  the  former  can  only  pass  through  after 
y.     -„  a  process  of  moulding  and  accommodation, 

/  y  x ,  which  is  usually  spoken  of  as  con-figuration. 

In  very  exceptional  cases  the  head  may  de- 
scend at  a  comparatively  early  period  into 
the  pelvic  cavity,  and  as  it  cannot  readily 
escape  it  undergoes  further  development  in 
the  pelvic  cavity,  and  in  consequence  pre- 
sents characteristic  deformities  at  birth,  the 
part  within  the  pelvis  being  markedly  flat- 
tened, while  that  above  it  is  unusually  large, 
as'  shown  in  Fig.  534. 

Under  the  influence  of  the  strong  uterine 
contractions,  the  various  bones  comprising 
the  skull  come  to  overlap  one  another  at  the 
various  sutures.  As  a  rule  the  median  mar- 
gin of  the  parietal  bone,  which  is  in  contact 
with  the  promontory,  becomes  overlapped  by 
that  of  its  fellow,  and  the  same  occurs  with 
the  frontal  bones.  The  occipital  bone,  on  the  other  hand,  becomes  shoved 
under  the  parietal  bones,  so  that  the  posterior  margins  of  the  latter  fre- 
quently overlap  it.  These  changes  are  usually  accomplished  without  detri- 
ment to  the  child,  though  when  the  distortion  is  marked  they  occasionally 
lead  to  rupture  of  the  longitudinal  sinus,  followed  by  fatal  haemorrhage. 

At  the  same  time  the  head  also  becomes  moulded,  and  the  parietal 
bone,  which  was  in  contact  with  the  promontory,  usually  shows  signs  of 


/ 


J 


Fig.  534. — Showing  Moulding  of 
Head  in  a  Generally  Con- 
tracted Ehachitic  Pelvis. 


COURSE  OF  LABOUR  IN  CONTRACTED  PELVES 


625 


having  been  subjected  to  marked  pressure,  sometimes  becoming  very  much 
flattened.  This  process  is  more  readily  accomplished  when  the  bones  of 
the  head  are  imperfectly  ossified,  in  rare  instances  the  skull  being  so  soft 
that  it  yields  to  pressure  as  readily  as  the  shell  of  a  soft  crab.    This  property 

is  of  marked  importance,  and  serves  to 
explain  the  difference  in  the  course  of 


Fig.  535. — Overlapping  of  Bones  of 

Skull  i  Tarnier  i. 


Fig.  536. — Overlapping  of  Bones  of 

Skull  (Tarnier). 


labour  in  two  apparently  similar  eases  in  which  the  pelvis  and  the  head 
present  identical  measurements.  In  the  one  the  head  is  soft  and  readily 
moulded,  so  that  spontaneous  labour  can  result;  in  the  other  the  more 
resistant  head  retains  its  original  shape,  and  a  severe  operative  procedure 
becomes  necessary  for  its  delivery. 

We  have  already  referred  to  the  pressure  marls  upon  the  scalp  covering 
the  portion  of  the  head  which  passes  over  the  promontory  of  the  sacrum. 
These  are  frequently  very  characteristic  in  appearance,  and  from  their 
course  enable  one  to  determine  the 
movements  which  the  head  has  un- 
dergone in  passing  through  the 
superior  strait.  Much  more  rarely 
similar  marks  appear  on  the  portion 
of  the  head  which  has  been  in 
contact  with  the  symphysis  pubis. 
These  marks  have  no  influence 
upon  the  well-being  of  the  child, 
and  usually  disappear  a  few  days 
after  birth,  although  in  exceptional 
instances  the  scalp  may  have  been 
subjected  to  such  severe  pressure  as 
to  lead  to  necrosis  and  sloughing. 

In  a  small  number  of  cases  frac- 
tures  of  the  skull  are  met  with. 
This  accident  usually  follows  vio- 
lent attempts  at  delivery,  though 
occasionally  it  may  occur  spontane- 
ously. These  fractures  are  of  two  varieties,  appearing  either  as  a  shallow, 
gutter-like  groove  or  as  a  spoon-shaped  depression  just  posterior  to  the 
coronal  suture.    The  former  is  relatively  common,  and  as  it  involves  only 


; 


Fig.  537. — Child  Born  Spontaneously  through 
Generally  Contracted  Bhachitic  Pel- 
vis. Conjugata  Vera  7.25  Centimetres, 
sin 'wing  Caput  Succedaneuh  and  De- 
pression of  Skull. 


626 


OBSTETRICS 


the  external  plate  of  the  bone  is  not  very  dangerous;  whereas  the  latter,  ac- 
cording to  Schroeder,  leads  to  the  death  of  the  child  in  about  50  per  cent  of 


Fig.  538. — Pressure  Marks  froji 
Promontory. 


Pig.  539. — Spoon-Shaped  Fracture  of  Skull 
(Tainier). 


the  cases,  since  it  extends  through  the  entire  thickness  of  the  skull  and  gives 
rise  to  projections  upon  its  interior,  which  exert  an  injurious  pressure  upon 
the  brain. 

Prognosis  for  the  Mother. — The  prognosis  as  to  the  outcome  of  labours 
complicated  by  contracted  pelves  depends  not  only  upon  the  degree  of  con- 
traction but  also  upon  the  other  factors  to  which  we  have  already  alluded. 
It  may  be  said,  however,  that  spontaneous  delivery  of  a  fully  developed  child 
rarely  occurs  when  the  conjugata  vera  measures  7  centimetres  or  less. 
Above  this  limit  it  will  occur  in  a  varying  proportion  of  cases,  and  becomes 
more  frequent  the  less  marked  the  pelvic  distortion. 

In  our  278  cases,  71.58  per  cent  of  the  children  were  delivered  spon- 
taneously, as  compared  with  68.6  per  cent  reported  by  G-laser,  69  per  cent 
by  Valency,  76.5  per  cent  by  Bar,  and  78.48  per  cent  by  Kronig.  The  prob- 
ability of  spontaneous  labour  decreases  with  the  degree  of  pelvic  contrac- 
tion. Thus,  in  our  material  a  spontaneous  termination  occurred  in  77.28 
per  cent  of  the  cases  when  the  conjugata  vera  measured  between  10  and  9 
centimetres;  in  61.54  per  cent  between  8.9  and  8  centimetres;  in  33^-  per 
cent  between  7.9  and  7  centimetres,  and  in  not  one  with  a  measurement 
below  7  centimetres.  The  experience  of  Ludwig  and  Savor  is  shown  by 
the  folloAYing  table: 

Conjugata  vera  9.5  c.  in.,  75.6$  spontaneous  labours. 
"    9        "       58.7$ 
"    8.5     "       49.7$ 
"    8        "       25$ 
"     7.5     "       15$ 
"    7        "       no 

Generally  speaking,  the  probability  of  spontaneous  labour  is  less  in  gen- 
erally contracted  than  in  flat  pelves  presenting  the  same  conjugata  vera, 
it  being  customary  to  calculate  that  half  a  centimetre  must  be  added  to  the 
conjugata  vera  of  the  former  to  reduce  it  to  terms  of  the  latter. 

The  clanger  to  the  mother  depends  upon  the  course  of  labour,  the  per- 


PROGNpSJS   OP    LABOUB    IX    CONTRACTED    PELVES  621 

fection  wit  1 1  which  aseptic  technique  is  observed,  and  the  treatment  pur- 
sued in  operative  cases.  Speaking  broadly;  the  maternal  mortality  after 
spontaneous  Labour  should  be  hardly  greater  than  thai  observed  with  nor- 
mal pelves,  if  the  case  is  conducted  properly  and  the  patient  is  among  good 
surroundings.  <>n  the  other  band,  it'  spontaneous  Labour  doe|  nol  occur, 
and  the  patient  is  Left  to  herself,  she  will  almost  always  die  undelivered, 
cither  from  haemorrhage  resulting  from  uterine  nipt  lire  or  from  infection. 
In  operative  cases  the  prognosis  depends  entirely  upon  the  choice  of  the 
operation,  the  surroundings  of  the  patient,  and  the  degree  of  perfection 
of  the  technique. 

In  our  27.8  cases  of  labour  complicated  by  contracted  pelves,  there  were 
8  maternal  deaths  (2.88  per  cent).  It  should  be  said,  hoyrever,  that  6  of 
these  patients  were  profoundly  infected  when  first  seen,  as  the  result  of 
attempts  at  delivery  outside  of  the  hospital,  and  cultures  taken  from  the 
uterine  cavity  immediately  after  the  expulsion  of  the  placenta  demon- 
strated the  presence  of  the  micro-organisms  which  caused  the  fatal  infec- 
tion, leaving  only  two  cases  whose  death  can  be  fairly  attributed  to  us — a 
mortality  of  0.72  per  cent. 

Bar,  in  1(36  cases,  had  one  maternal  death — a  mortality  of  0.59  per  cent 
— and  Ludwig  and  Savor  reported  a  maternal  mortality  of  0.8  per  cent  in 
706  eases  of  spontaneous  labour  complicated  by  contracted  pelves,  as  com- 
pared with  5.2  per  cent  in  591  operative  cases.  All  these  results,  however, 
were  obtained  within  the  last  few  years — after  the  perfection  of  aseptic 
technique.  Previously,  such  results  were  impossible,  as  Michealis  and  Litz- 
mann  reported  a  mortality  of  10  per  cent  and  7.3  per  cent  respectively. 

A  very  instructive  comparison  between  the  conditions  existing  then 
and  now  was  furnished  by  Tarnier,  who  stated  that  the  maternal  mortality 
was  22  per  cent  in  334  cases  occurring  in  the  Maternite  in  Paris  between 
the  years  1860  and  1869,  as  compared  with  1.91  per  cent  in  1,036  cases 
occurring  between  1881  and  1892.  In  the  latter  series  761  labours  were 
spontaneous,  with  a  mortality  of  0.78  per  cent,  and  there  were  272  operative 
cases  with  a  mortality  of  5.15  per  cent. 

Prognosis  for  the  Child. — The  prognosis  for  the  foetus  is  always  more 
serious  in  contracted  than  in  normal  pelves,  even  though  labour  occurs 
spontaneously.  It  likewise  depends  to  a  great  extent  upon  the  methods 
chosen  for  delivery;  and,  broadly  speaking,  it  may  be  said  that  the  foetal 
mortality  increases  with  the  degree  of  pelvic  contraction,  unless  Cesarean 
section  is  frequently  performed.  This  is  clearly  shown  by  the  following 
table  of  Michealis,  Litzmann,  and  Schwartz: 

Conjugata  vera  9.25  —  8.5  cm.,  foetal  mortality     5#. 
«    8.4    -7.5    "         "  "        16.9f?. 

"     7.4    —  7      "        "  "        52.9g. 

According  to  Ludwig  and  Savor  the  mortality  was  9.1  per  cent  in  706 
spontaneous  labours  as  compared  with  46.3  per  cent  in  591  operative  cases. 
Bar  reports  a  mortality  in  11  per  cent  in  127  spontaneous,  and  23  per  cent 
in  39  operative  labours.  The  difference  between  the  results  obtained  by 
the  latter  and  by  Ludwig  and  Savor  is  due  to  the  fact  that  Bar  performed 
41 


628  OBSTETRICS 

Csesarean  section  frequently,  while  Ludwig  and  Savor  resorted  to  craniot- 
omy in  the  difficult  cases. 

In  our  278  cases  36  children  were  horn  dead,  a  mortality  of  12.96  per 
cent.  One  half  of  these,  however,  died  from  causes  not  connected  with  the 
condition  of  the  pelvis,  being  macerated  or  having  died  from  eclampsia. 
The  other  half — 6.5  per  cent- — however,  died  directly  from  the  effects  of  the 
pelvic  deformity  or  from  operations  performed  for  its  relief.  Of  these 
children,  however,  7  were  dead  when  first  seen,  having  succumbed  to  a  too 
prolonged  labour  or  to  operative  measures  undertaken  outside  of  the  hos- 
pital; leaving  11,  or  -1  per  cent,  who  died  in  our  hands. 

Treatment  of  Labour  complicated  by  Contracted  Pelves. — The  treatment 
of  labour  complicated  by  contracted  pelves  varies  according  to  the  degree  of 
contraction  and  the  possibility  of  the  occurrence  of  spontaneous  labour. 
Greneralry  speaking,  a  normally  developed  full-term  child  cannot  be  born 
spontaneously  when  the  conjugata  vera  measures  le_ss  than  7  centimetres 
in  flat,  and  7.5  centimetres  in  generally  contracted  pelves;  above  these  limits 
its  possibility  steadily  increases  as  the  contraction  becomes  less  marked. 

We  have  therefore  to  consider  in  the  first  place  the  treatment  of  two 
great  groups  of  pelvic  deformities — those  below  and  those  above  the  limits 
just  mentioned.  In  the  first  group  the  problem  is  comparatively  simple, 
whereas  in  the  latter  it  is  ofttimes  extremely  complex  and  requires  the 
utmost  nicety  of  judgment  for  its  proper  solution. 

Conjugata  Vera  less  than  7  Centimetres  in  Flat,  or  7.5  Centimetres  in 
Generally  Contracted  Pelves. — When  the  pelvic  contraction  falls  within  these 
limits  the  treatment  will  vary  according  as  the  child  is  alive  or  dead,  and 
also  depends  upon  the  physical  condition  of  the  mother  and  her  sur- 
roundings. 

If  the  deformity  be  diagnosed  during  pregnancy,  the  patient  should 
be  sent  to  a  well-regulated  hospital  for  the  performance  of  Cesarean  sec- 
tion within  a  few  days  of  the  expected  elate  of  confinement  or  at  the  onset 
of  labour  pains,  as  the  operator  deems  best.  Such  a  procedure  will  give 
almost  ideal  results,  and  all  of  the  children  and  nearly  all  of  the  mothers 
should  be  saved,  inasmuch  as  the  maternal  mortality  following  Cesarean 
section,  when  performed  by  competent  operators  upon  healthy  women,  need 
not  exceed  that  following  the  removal  of  ovarian  cystomata. 

On  the  other  hand,  if  the  condition  of  the  pelvis  is  not  diagnosed  until 
the  woman  has  fallen  into  labour,  the  treatment  to  be  pursued  will  vary 
with  circumstances.  If  the  patient  is  uninfected,  has  not  been  examined 
repeatedly  by  the  vagina,  and  is  among  suitable  surroundings,  Cesarean 
section  will  offer  every  prospect  for  saving  both  mother  and  child,  pro- 
vided the  latter  is  in  good  condition  and  a  competent  operator  is  procurable. 
But  if  the  patient  is  infected  or  the  child  is  dead  or  dying,  the  line  of 
treatment  to  be  pursued  will  be  determined  by  the  degree  of  pelvic  contrac- 
tion. If  the  conjugata  vera  be  above  5  centimetres,  craniotomy  should  be 
performed;  but  with  a  measurement  below  this  limit  we  have  to  deal  with 
the  absolute  indication  for  Cesarean  section,  no  matter  what  the  condi- 
tion of  the  child  or  the  mother,  as  under  such  circumstances  the  delivery  of 
a  mutilated  child  through  the  natural  passages  will  be  impossible,  or  at 


TREATMENT  OF  LABOUR  IN  CONTRACTED  PELVES     629 

leasl  more  dangerous  to  the  mother  than  the  performance  of  Cesarean 
section,  even  under  satisfactory  conditions.  If  the  patienl  is  infected,  the 
delivery  of  the  child  should  be  followed  by  a  total  hysterectomy,  whereas 
the  classical  conservative  operation  should  be  chosen  if  she  i-  in  good 
condition.  Symphyseotomy  should  not  be  though!  of  hen',  as  its  field  of 
usefulness  is  Limited  to  those  cases  in  which  the  conjugata  vera  measures 
at  leasl  '>  centimetres. 

Conjugata  Vera  above  1  Centimetres  in  Flat,  mid  7.5  Centimetres  in  Gen- 
erally  <  'ont racted  Pelves. — Here  the  question  as  to  the  proper  treatment 
cannot  be  so  readily  disposed  of,  since  definite  rules  cannot  be  Laid  down 
for  the  entire  group,  and  each  case  must  be  considered  upon  its  own 
merits. 

We  know  in  general  that  spontaneous  labour  will  occur  in  many  of 
these  cases,  and  that  its  frequency  increases  with  a  lessening  degree  of 
pelvic  contraction.  But  at  the  same  time  it  is  very  difficult  to  predict 
what  will  occur  in  an  individual  case,  as  we  have  to  reckon  not  only  with  the 
degree  of  pelvic  deformity,  but  also  with  the  size  of  the  child's  head, 
the  extent  to  which  it  may  become  moulded  and  compressed,  and  the  char- 
acter of  the  labour  pains.  Moreover,  although  we  can  determine  the  size  of 
the  pelvis  with  tolerable  accuracy,  unfortunately  we  can  form  only  a  very 
imperfect  estimate  concerning  the  other  factors;  and  until  some  method  is 
devised  by  which  this  becomes  possible,  the  treatment  of  labour  complicated 
by  moderate  degrees  of  contraction  will  remain  a  very  difficult  problem. 

Methods  of  Determining  the  Size  of  Head. — Despite  the  existence  of  nu- 
merous methods  devised  for  accurately  determining  the  size  of  the  head, 
we  are  still  without  one  that  is  thoroughly  satisfactory. 

In  muciparous  women,  important  information  can  occasionally  be 
gained  from  the  character  of  the  heads  of  previous  children  of  the  same 
mother;  and  if  they  were  large  and  firmly  ossified,  it  is  extremely  probable 
that  the  child  in  question  will  possess  a  head  showing  similar  characteris- 
tics, and  that  it  may  even  be  somewhat  larger,  as  it  is  well  known  that  the 
size  is  liable  to  increase  with  successive  pregnancies. 

Again,  in  some  instances,  lliiller's  method  of  impression  may  afford  mate- 
rial aid.  In  making  use  of  this  procedure,  the  patient  having  been  anaes- 
thetized, the  obstetrician  seizes  the  brow  and  occiput  of  the  child  with  his 
fingers  through  the  abdominal  wall  and  makes  firm  pressure  downward  in 
the  axis  of  the  superior  strait,  the  effect  of  which  may  be  controlled  by  the 
fingers  of  an  assistant  in  the  vagina.  If  there  be  no  disproportion,  the 
head  will  readily  enter  the  pelvis  and  spontaneous  labour  may  be  pre- 
dicted. On  the  other  hand,  the  fact  that  the  head  cannot  be  forced  into 
the  superior  strait  does  not  necessarily  indicate  that  spontaneous  labour 
is  out  of  the  question,  as  we  have  no  means  of  foretelling  the  extent  to  which 
moulding  and  configuration  will  occur  at  the  time  of  labour. 

A  somewhat  similar  method  is  employed  by  Pinard — le  palper  mensura- 
teur.  In  this  procedure,  the  brow  and  occiput  having  been  grasped  by  the 
two  hands,  the  head  is  moved  from  side  to  side,  so  as  to  bring  it  into  close 
contact  with  the  pelvic  brim.  When  this  is  accomplished,  one  hand  is 
placed  upon  the  child's  neck  and  the   head  pushed  strongly  downward 


630  OBSTETRICS 

and  backward  so  as  to  bring  its  posterior  portion  in  close  contact  with  the 
promontory.  An  attempt  is  then  made  to  insinuate  the  fingers  of  the 
other  hand  between  the  anterior  surface  of  the  head  and  the  symphysis. 
If  this  can  be  done  it  indicates  that  there  is  no  disproportion;  but  if  it  is 
impossible,  and  the  anterior  portion  of  the  head  forms  a  prominent  tumour 
over  the  symphysis  pubis,  the  probabilities  are  that  engagement  will 
not  occur. 

Ahlfeld  showed  that  the  biparietal  diameter  of  the  head  bears  a  definite 
relation  to  the  length  of  the  child,  and  suggested  attempting  to  measure  the 
latter  in  uterp.  To  do  this,  one  blade  of  the  pelvimeter  is  placed  upon  the 
abdomen  over  the  breech  of  the  child,  while  the  other  is  introduced  into  the 
vagina  and  applied  to  the  vertex.  The  measurement  thus  obtained  is  taken 
to  represent  one  half  the  length  of  the  child,  and  from  this  the  size  of  the 
head  is  calculated,  as  shown  by  the  following  table: 

For  a  child  50  cm.  long,  biparietal  diameter  9.06  cm. 

"       "      49    "       "              "  "          8.72    " 

"      "      48    "      "              "  "         8.56    " 

"       "      47    "       "              "  "         8.44    " 

"       "      46    "       "              "  "          8.34    " 

These  figures,  however,  represent  only  the  average  obtained  from  the  meas- 
urements of  a  number  of  children,  but  do  not  necessarily  hold  good  for  any 
given  case. 

All  of  these  methods  may  be  employed  during  pregnancy  or  at  the  time 
of  labour,  and  not  infrequently  give  us  valuable  information.  But  at  the 
same  time  they  afford  no  indication  as  to  the  consistency  or  the  extent 
to  which  the  head  may  become  moulded.  Accurate  information  as  to  this 
point  can  be  gained  only  by  watching  the  course  of  labour  during  the 
second  stage.  In  not  a  few  cases  a  fairly  correct  estimate  may  be  arrived 
at  by  anesthetizing  the  patient  soon  after  complete  dilatation  has  taken 
place,  and  carefully  examining  the  head  with  the  entire  hand  in  the 
vagina,  aided,  if  necessary,  by  pressure  from  above. 

Full  details  concerning  this  subject  are  to  be  found  in  the  recent  articles 
of  Denys  and  Dardel. 

Tor  convenience  in  considering  the  treatment  in  this  class  of  pelvic 
deformities,  it  is  advisable  to  subdivide  them  into  two  groups.  In  the  first 
the  conjugata  vera  varies  from  10  to  9  centimetres  in  generally  contracted, 
and  from  9.5  to  8.5  centimetres  in  flat  pelves;  while  in  the  second  group 
it  varies  from  8.9  to  7.5  centimetres,  and  from  8.4  to  7  centimetres  re- 
spectively. 

Conjugata  Vera  from  10  to  9  and  9.5  to  8.5  Centimetres. — Spontaneous 
labour  is  the  rule  in  pelves  belonging  in  this  category,  unless  the  head  is 
unusually  large  or  the  expulsive  forces  are  very  deficient,  since  a  moderate- 
sized  head  will  become  moulded  sufficiently  to  pass  through  the  contracted 
superior  strait.  Accordingly,  in  pelves  of  this  character  the  course  of 
labour  should  be  left  to  Nature  as  long  as  possible,  and  interference  re- 
sorted to  only  when  absolutely  necessary.  In  most  cases  the  head  becomes 
engaged   and  generally   descends   into   the   pelvis   after   a   few   hours   of 


TREATMENT   OP    bABOUB    IN    ('ONTKA(TKI)    I'KLVKS 


631 


second-stage  pains,  or  al  least  becomes  sulliciently  moulded  to  permit  the 
safe  application  of  high  or  mid  forceps. 

On  the  other  haml,  if  engagement  fails  to  occur  after  complete  dilata- 
tion of  the  cervix,  the  patient  should  be  placed  in  AYalcher's  position  for  as 
Long  a  time  as  she  will  bear  it.     In  many  cases  this  procedure  will  bring 
ahoui  a  Lengthening  of  the  ante- 
rior posterior  diameter  of  the  su- 
perior strait    sufficient   to   permit 
engagement.     As  soon  ,-is  the  head 
has  descended  into  the  pelvis  the 
patient     should     he     placed     upon 
her  hack,  as  the  hanging  position 
tends  to  contract    the   pelvic   out- 
Lei   and  thus  retards  delivery. 

If  the  child  should  die  during 
the  course  of  labour,  craniotomy 
should  be  resorted  to  without  hes- 
itation, as  it  is  far  safer  for  the 
mother  than  the  application  of 
forceps,  unless  the  greatest  di- 
ameter of  the  head  has  already 
passed  the  contracted  portion  of 
the  pelvis. 

Conjugata  Vera  8.9  to  7.-5  and 
S.Jf  to  7  Centimetres. — It  is  in 
pelves  contracted  within  these 
limits  that  the  greatest  difficulty 
is  experienced  in  predicting  the 
course  of  labour  and  in  laying 
down  rules  for  treatment.  About 
one  half  of  the  patients  will  be 
delivered  spontaneously,  the  num- 
ber decreasing  as  the  lower  limit 

is  approached;  but  at  the  same  Fig.  540  —  Walcher's  Hanging  Position  (Bumm). 
time   it   is  impossible   to   foretell 

what  will  occur  in  a  given  case.  Accordingly,  the  labour  should  be  left 
to  Nature  as  far  as  possible,  in  the  hope  that  spontaneous  delivery  will 
result,  unless  the  history  of  previous  labours  or  the  excessive  size  of  the 
child's  head  renders  it  almost  certain  that  such  a  termination  is  out  of  the 
question.  The  most  rigorous  aseptic  technique  should  be  employed,  and 
the  course  of  labour  followed  by  external  palpation,  internal  examination 
being  restricted  as  far  as  possible.  If  the  condition  of  the  pelvis  has  been 
ascertained  before  labour,  a  vaginal  examination  should  not  be  made  until 
after  rupture  of  the  membranes,  as  there  is  no  possibility  of  the  head  de- 
scending before  its  occurrence.  The  fcetal  heart,  of  course,  should  be 
auscultated  at  frequent  intervals. 

In  a  large  number  of  cases  spontaneous  delivery  will  occur  after  a 
longer  or  shorter  second  stage;  but  if  the  head  shows  no  tendency  to 


632  OBSTETRICS 

descend  after  several  hours  of  efficient  second-stage  pains,  a  spontaneous 
termination  can  scarcely  be  hoped  for,  and  it  then  remains  to  determine 
what  will  be  the  most  desirable  method  of  delivery. 

If  the  patient  is  in  a  well-regulated  hospital,  or  can  be  surrounded  by 
every  convenience  in  her  own  home,  the  second  stage  of  labour  should  be 
allowed  to  go  on  for  one  or  two  hours  before  the  internal  examination  is 
made.  If  at  that  time  the  head  is  found  to  be  well  moulded  but  still  above 
the  superior  strait,  and  shows  no  sign  of  advance,  the  pains  having  been 
efficient,  Cesarean  section  or  symphyseotomy  .should  be  considered,  accord- 
ing to  the  preference  of  the  operator.  The  necessary  preparations  for  the 
operation  should  then  be  made  and  the  patient  anaesthetized.  But  be- 
fore proceeding  to  operate  a  thorough  vaginal  examination  should  be  made 
with  the  entire  hand,  and  the  size  and  character  of  the  head  estimated. 
If  there  seems  to  be  no  likelihood  of  engagement  occurring,  the  opera- 
tion should  be  performed  at  once,  but  in  other  cases  it  should  be  de- 
ferred. 

On  the  other  hand,  if  the  patient  be  in  a  tenement  house  and  refuses 
to  enter  a  hospital,  or  is  in  the  country  where  the  physician  cannot  com- 
mand the  necessary  assistance  and  appliances  for  an  aseptic  operation,  the 
second  stage  should  be  allowed  to  continue  until  the  appearance  of  signs 
of  danger  on  the  part  of  the  mother  or  child.  Occasionally  spontaneous 
labour  will  occur  contrary  to  all  expectation.  Tailing  such  a  fortunate  out- 
come, forceps  should  be  applied  obliquely  to  the  head  and  a  few  tractions 
made.  If  the  head  shows  a  tendency  to  advance,  they  should  be  persisted 
in,  but  if  not,  the  instrument  should  be  removed  and  craniotomy  performed 
at  once.  In  such  cases  forceps  should  be  employed  only  tentatively,  it 
being  understood  that  prolonged  traction  and  brutal  methods  of  extraction 
are  positively  contra-indicated,  as  by  their  means  the  child  is  almost  as 
surely  lost  as  by  craniotomy,  while  the  life  of  the  mother  is  unnecessarily 
endangered. 

Of  course  if  the  patient  is  a  devout  Catholic,  the  well-known  views 
of  that  Church  concerning  craniotomy  must  be  recognised,  and  the 
physician  may  feel  called  upon  to  perform  Cassarean  section  when,  from 
a  purely  professional  point  of  view,  its  justifiability  might  be  open  to 
criticism. 

In  all  grades  of  moderately  contracted  pelves,  craniotomy  should  always 
be  performed  if  the  child  has  died  during  the  course  of  labour,  as  any  other 
operation  subjects  the  mother  to  increased  danger  for  the  purely  senti- 
mental consideration  of  not  mutilating  the  child. 

Likewise,  if  the  patient  has  not  been  seen  until  far  advanced  in  labour, 
and  has  been  repeatedly  examined  by  persons  not  skilled  in  aseptic  tech- 
nique, or  if  she  presents  symptoms  indicative  of  a  beginning  infection, 
Caasarean  section  is  contra-indicated  on  account  of  its  very  high  mortality 
under  such  circumstances.  Tentative  attempts  at  delivery  with  forceps 
.should  be  made,  and  if  these  fail  craniotomy  should  be  performed  unless 
the  patient  is  very  anxious  for  a  living  child  and  is  willing  to  undergo  the 
markedly  increased  risks  of  Csesarean  section  after  these  have  been  clearly 
set  before  her  and  her  family.    In  such  cases  the  entire  uterus  should  be 


TREATMENT  OF  LABOUR  IX  CONTRACTED  PELVES     633 

removed.  X"t  a  few  authorities  advise  symphyseotomy  under  these  condi- 
tions, inn  in  my  opinion  the  results  obtained  are  by  no  means  commensu- 
rate with  the  added  risk  to  which  the  patienl  is  subjected. 

[f  the  Line  of  treatment  which  we  have  outlined  for  hospital  practice 
be  rigorously  carried  out,  I  feel  sure  thai  the  foetal  mortality  will  hardly 
exceed  thai  occurring  in  normal  Labour,  while  the  maternal  mortality 
will  be  reduced  to  a  minimum.  Od  the  other  hand,  when  the  forceps  is 
employed  tentatively  and  followed  by  craniotomy  in  unsuccessful  cases,  the 
foetal  mortality  will  approach  50  per  cent,  but  the  danger  to  the  mother 
will  be  only  slightly  increased. 

Breech  and  Face  Presentations  in  Contracted  Pelves. — The  existence  of 
a  breech  presentation  in  moderate  degrees  of  pelvic  deformity  should  be 
regarded  as  a  complication  especially  unfavourable  for  the  child,  inas- 
much as  in  the  early  stages  of  labour  prolapse  of  the  cord  is  facilitated  and 
in  the  later  stages  serious  delay  may  be  encountered  in  the  delivery  of  the 
after-coming  head,  which  is  followed  by  almost  uniformly  fatal  results. 
On  the  other  hand,  so  far  as  the  mother  is  concerned  it  is  rather  favourable, 
for  the  soft  breech  does  not  subject  her  soft  parts  to  such  injurious  pressure 
as  the  hard  head;  and  if  delivery  becomes  imperative,  extraction  can  usually 
be  accomplished  without  great  difficulty,  unless  the  pelvic  contraction  is 
very  marked.     In  most  of  these  cases,  however,  the  child  is  sacrificed. 

In  frank  breech  presentations,  when  there  is  reason  to  believe  that 
operative  interference  will  become  necessary  and  the  pelvis  is  but  slightly 
contracted,  it  is  advisable,  as  a  prophylactic  measure,  to  bring  down  one 
fool  soon  after  rupture  of  the  membranes,  so  that  prompt  delivery  can  be 
effected  when  indicated. 

Face  .and  brow  presentations  should  be  regarded  as  much  more  serious 
complications,  as  their  existence  usually  indicates  a  marked  degree  of  dis- 
proportion and  an  increased  probability  of  the  necessity  for  operative  inter- 
ference. If  the  pelvic  contraction  is  at  all  serious,  too  much  should  not 
be  expected  from  Xature,  and  radical  measures  should  be  promptly  em- 
ployed. On  the  other  hand,  when  one  feels  fairly  satisfied  that  the  dis- 
proportion is  not  excessive  and  can  be  overcome,  an  attempt  should  be 
made  to  convert  the  presentation  into  a  vertex  by  one  of  the  recognised 
procedures. 

Use  of  Forceps  in  Contracted  Pelves. — Generally  speaking,  the  employ- 
ment of  forceps  is  contra-indicated  in  contracted  pelves,  especially  when 
the  head  is  freely  movable  above  the  superior  strait.  The  persistence  of  the 
condition  after  several  hours  of  efficient  second-stage  pains  generally  indi- 
cates that  the  disproportion  between  the  head  and  pelvis  is  too  great  to  be 
overcome.  In  such  cases  forcible  attempts  to  drag  the  head  through  the 
pelvis  will  lead  to  fatal  injury  of  the  child,  and  not  infrequently  to  the  death 
of  the  mother  or  to  serious  lesions  on  her  part.  Too  many  cases  in  hospital 
and  consultation  practice  abundantly  bear  out  the  truth  of  this  assertion. 
On  the  other  hand,  the  tentative  application  of  forceps,  after  the  head  has 
become  well  moulded  and  is  fixed  at  the  pelvic  brim,  is  a  justifiable  pro- 
cedure, provided  brutal  traction  is  not  made. 

When  the  greatest  circumference  of  the  head  has  passed  the  superior 


634  OBSTETRICS 

strait,  the  employment  of  forceps  is  governed  by  the  same  rules  as  in  nor- 
mal pelves,  for  in  snch  cases  the  operation  is  not  performed  on  account  of 
the  contracted  pelvis,  but  for  one  of  the  usual  indications. 

Version  in  Contracted  Pelves. — Version  is  frequently  recommended  as  a 
satisfactory  method  in  delivery  in  contracted  pelves,  and  many  authorities 
compare  its  advantages  with  those  obtained  with  the  forceps. 

Sir  James  Y.  Simpson  pointed  out  that  the  after-coming  head  offered 
more  favourable  conditions  than  the  vertex  for  passing  through  the  con- 
tracted superior  strait,  as  smaller  diameters  are  the  first  to  encounter  and 
overcome  the  resistance  offered  by  the  pelvis.  But  although  version  un- 
doubtedly presents  some  advantages  so  far  as  the  mother  is  concerned, 
these  are  more  than  counterbalanced  by  the  dangers  to  which  it  exposes  the 
child.  Thus  Eosenthal  states  that  the  foetal  mortality  attending  this  opera- 
tion in  Leopold's  clinic  was  35  per  cent.  Moreover,  the  advantages  of 
version  are  markedly  diminished  by  the  fact  that  it  must  be  performed  soon 
after  rupture  of  the  membranes  if  satisfactory  maternal  results  are  to  be 
obtained.  This  limits  considerably  its  range  of  iisefulness,  as  one  is  com- 
pelled to  operate  before  the  uterine  contractions  have  had  an  opportunity 
to  exert  their  full  effect  in  moulding  the  head,  and  consequently  version 
is  done  in  many  cases,  which  if  let  alone  would  have  terminated  spon- 
taneously. 

Formerly  many  of  the  German  authorities  recommended  the  perform- 
ance of  so-called  prophylactic  version — turning  at  the  onset  of  the  second 
stage — in  all  cases  of  moderate  disproportion.  This  practice,  however, 
would  not  appear  justifiable  for  several  reasons.  In  the  first  place,  it  does 
away  with  the  possibility  of  spontaneous  labour  and  converts  all  into  opera- 
tive cases;  and,  on  the  other  hand,  when  the  operation  is  performed  at  the 
proper  time,  the  head  has  had  no  chance  of  becoming  moulded,  and  accord- 
ingly must  be  dragged  through  the  pelvis  with  only  such  diminution  in 
size  as  results  from  a  few  minutes'  traction.  Moreover,  the  death  of  the 
child  is  inevitable  if  any  serious  obstacle  to  extraction  is  experienced,  as 
only  a  few  minutes  can  elapse  between  the  birth  of  the  umbilicus  and  the 
delivery  of  the  head,  and  sufficient  time  is  not  available  to  permit  of  any 
other  operation  being  performed  in  the  hope  of  saving  the  child.  For  these 
reasons  a  mistake  in  the  estimation  of  the  degree  of  disproportion  always 
results  in  foetal  death. 

Induction  of  Premature  Labour. — In  moderate  degrees  of  pelvic  deform- 
ity, many  authorities  recommend  the  induction  of  premature  labour  at  the 
thirty-fourth  or  thirty-sixth  week  of  pregnancy,  in  the  hope  that  the  smaller 
and  softer  head  will  be  born  more  readily  than  at  term.  This  is  un- 
doubtedly the  case,  and  the  operation,  if  properly  performed,  is  practically 
without  clanger  for  the  mother.  Personally,  I  have  never  induced  labour 
for  this  indication  and  do  not  recommend  the  procedure.  It  is  applicable 
only  to  very  moderate  degrees  of  contraction,  and  the  children  not  infre- 
quently succumb  to  the  operation,  or,  when  born  alive,  are  in  so  imperfect 
a  state  of  development  that  even  with  the  most  careful  attention  hardly 
more  than  50  per  cent  survive  the  first  few  months. 

Schoedel,  in  1901,  reported  a  mortality  of  36.6  per  cent  from  Leopold's 


TREATMENT  OF  LABOUR  IX  CONTRACTED  PELVES     635 

clink-,  and  gives  a  table  showing  the  results  of  other  operators.  These 
results,  id  1 1 1 \  mind,  are  nol  so  good  as  those  following  the  expectant 
treatment  at  full  term,  and  are  far  inferior  to  those  following  the  more 
general  performance  of  Cassarean  section  in  the  class  of  eases  under  dis- 
cussion. Indeed,  the  l'<  •'!  a  I  mortality,  direct  and  indirect,  attending  the 
induction  of  premature  Labour  is  so  great  that  it  appears  to  be  merely  a 
question  of  degree  between  its  employmeni  and  bringing  about  artificial 
abortion  in  the  early  months  of  pregnancy. 

In  conclusion,  it  cannot  be  too  forcibly  impressed  upon  the  general 
practitioner  and  the  student  that  the  repeated  delivery  of  dead  children 
in  cases  of  contracted  pelves  is  absolutely  unjustifiable.  The  loss  of  a 
child  is  frequently  perfectly  excusable  in  a  single  pregnancy,  but  its  repeat- 
ed occurrence  indicates  a  neglect  of  human  life  which  should  not  be  toler- 
ated, and  physicians  should  learn  that  it  is  their  duty,  if  they  do  not  feel 
competent  to  cope  successfully  with  such  cases,  to  send  them  to  a  well- 
regulated  hospital  or  to  confide  them  to  the  care  of  a  competent  specialist 
for  appropriate  treatment. 

Treatment  of  Labour  complicated  by  Osteomalacic  Pelves. — The  course 
of  labour  in  osteomalacic  pelves  varies  according  to  the  stage  of  the  dis- 
ease and  the  degree  of  contraction.  When  the  deformity  is  slight  its 
influence  upon  the  labour  is  minimal,  but  when  marked  it  not  infrequently 
gives  the  absolute  indication  for  Csesarean  section. 

Some  idea  of  the  obstacles  offered  to  labour  by  this  class  of  pelves  may 
be  gained  from  the  figures  of  Litzmann,  who  in  1861  collected  from  the 
literature  and  tabulated  79  cases.  He  found  that  the  following  opera- 
tions had  been  performed:  10  Cesarean  sections,  16  perforations,  1  sym- 
physeotomy, 2  inductions  of  premature  labour;  while  7  women  had  suc- 
cumbed to  rupture  of  the  uterus,  and  4  others  had  died  undelivered. 

Latzo,  in  1897,  considered  the  effect  of  osteomalacia  upon  the  course 
of  labour  in  85  patients  who  came  under  his  observation.  The  women  in 
question  had  159  labours,  290  of  which  occurred  before  and  169  after 
the  appearance  of  the  disease.  In  the  first  group,  operative  interference 
was  necessary  once  in  every  18  cases,  and  in  the  second  once  in  every 
4.9  cases,  thus  showing  that  labour  had  become  about  10  times  more 
difficult. 

If  the  patient  is  seen  during  the  early  months  of  pregnancy  and  is  suffer- 
ing from  the  disease  in  its  acute  stage,  she  should  be  at  once  removed  to  a 
hospital  where  she  can  live  under  the  best  hygienic  surroundings  and  be  sup- 
plied with  an  abundance  of  suitable  food.  Phosphorus  in  doses  of  2.4  to  4 
milligrammes  per  day  in  pill  form  or  combined  with  cod-liver  oil  or  almond 
oil  should  be  given,  as  Latzo,  Winckel,  and  others  claim  that  many  cases  can 
be  permanently  cured  by  its  administration. 

On  the  other  hand,  if  the  patient  is  not  seen  until  the  end  of  pregnancy 
or  the  time  of  labour,  the  treatment  to  be  pursued  depends  altogether 
upon  the  degree  of  pelvic  contraction.  In  such  cases  attention  should 
be  paid  not  only  to  the  length  of  the  conjugata  vera,  but  more  particularly 
to  the  dimensions  of  the  inferior  strait,  as  the  pelvic  outlet  is  usually  very 
markedly  contracted. 


636  OBSTETRICS 

In  florid  cases  the  bones  may  be  so  soft  as  to  resemble  leather  in  con- 
sistency, and  the  pelvis  readily  assumes  various  forms.  This  affords  an 
explanation  for  the  fact  that  one  is  occasionally  surprised  to  see  delivery 
accomplished  through  a  pelvis  which  at  first  glance  appears  to  offer  no 
possibility  of  such  an  occurrence.  Quite  a  number  of  such  cases  are  re- 
ferred to  in  Schroeder's  text-book,  but  such  an  outcome  should  be  regarded 
as  very  exceptional,  and  should  not  lead  us  to  expect  too  much  of  Nature. 

If  the  pelvis  is  markedly  contracted,  Csesarean  section  should  be  per- 
formed without  hesitation,  followed  by  the  removal  of  the  uterus  and 
ovaries  or  by  castration  alone.  Fehling  has  shown  that  either  of  these 
operations  leads  to  the  permanent  cure  of  the  disease  in  about  80  per  cent 
of  the  cases,  and  his  results  have  been  confirmed  by  Lohlein,  Schauta, 
Latzo,  and  many  other  observers.  On  the  other  hand,  if  delivery  occurs 
spontaneously,  or  has  been  effected  by  forceps  or  version,  castration  should 
be  performed  soon  after  the  puerperium  in  the  hope  of  checking  the 
disease. 

Exactly  why  this  operation  should  have  such  a  marked  effect  has  not 
as  yet  been  definitely  determined.  As  was  said  in  the  preceding  chapter, 
Fehling  considers  the  disease  as  a  trophoneurosis  of  ovarian  origin,  and 
believes  that  the  removal  of  the  ovaries  does  away  with  the  reflex  stimulation 
of  the  vaso-dilators,  which  he  considers  plays  so  important  a  part  in  the 
production  of  the  bone  changes. 

Caratulo  and  Tarulli  made  careful  studies  of  the  metabolism  occurring 
in  dogs  before  and  after  castration,  and  showed  that  the  excretion  of  lime 
salts  and  phosphoric  acids  was  markedly  diminished  after  it.  Hence  they 
argue  that  the  presence  of  the  ovaries  in  some  way  either  favours  decal- 
cification or  prevents  calcification  of  the  newly  formed  osteoid  tissue. 
Their  conclusions,  however,  have  lately  been  denied  by  Falk,  and  can- 
not be  accepted  without  reserve  until  further  confirmation  is  supplied 
by  the  work  of  other  observers. 


LITERATURE 

Ahlfeld.    Ueber  die  Zerreissung  der  Schamfnge  wahrend  der  Geburt.    D.  I.,  Leipzig,  1868. 
Bestimmungen  der  Grosse  und  des  Alters  der  Frucht  vor  der  Geburt.     Archiv  f.  Gyn., 

1871.  ii,  353-372. 
Bar.     Lecons  de  pathologie  obstetricale.     Paris,  1900. 
Braun  von  Fernwald.     Ueber  Symphysenlockerung  und  Symphysenruptur.     Archiv  f. 

Gyn.,  1894,  xlvii,  104-129. 
Breisky.      Extramediane  Einstellung  des  Kindeskopfes,  etc.     Archiv  f.  Gyn.,  1870.  i, 

173-174. 
Caratulo  et  Tarulli.     Comment  la  castration  guerit  l'osteomalacie.     Annales  de  gyn. 

et  d'obst.,  1897,  xlvii,  239-250. 
Dardel.     Sur  1'evaluation  du  diametre  bi-parietal  du  foetus,  etc.     These  de  Paris,  1898. 
De  Lee.     Two  Cases  of  Rupture  of  the  Symphysis  Pubis  during  Labour.     Amer.  Jour. 

Obst.,  1893,  xxxviii,  483-499  (full  literature) ;  also  1901,  xliii,  630-633. 
Denys.     Mensuration  de  la  tete  fcetale  pendant  la  vie  intra-uterine.    These  de  Paris,  1897. 
Falk.     Ein   Beitrag   zur   Kenntniss  des  Stoffwechsels   nach   Entfernung  der  Ovarien. 

Archiv  f.  Gyn.,  1899,  lviii,  565-579. 


EFFECT  OF  PELVIC  ANOMALIES  OPON  PREGNANCY  AND  LABOUB      637 

Fehling.     Oeber  Wesen  und  Behandlung  der  puerperalea  Osteomalacic    Archiv  f.Gyn. 
L891,  xxxix.  171-196. 
[Jeber  Osteomalacic    Zeitschr.  ('.  Geb.  u.  Gyn.,  1894,  xxx.  I71-I7ii. 
Weitere  Beit  rfige  zur  Lehre  von  der  <  Isteomalacie.    Archiv  f.  Gyn.,  1895,  xlviii,  472-498. 

Glaser.     Oeber  spontane  Geburten  bei  engen  Becken.     D.  I..  Mtinchen,  1898. 

KrOnig.    Die  Therapie  bei  engen  Becken.    Leipzig,  1901. 

L  \  Torre.     Die  developpement  du  feel  us  chez  les  I'emnirs  a  h.-issin  vicir.     Paris.  lss7. 

Latzo.     Beitrage  zur  Diagnose  und  Therapie  der  Osteomalacie.     Monatsschr.  f.  Geb.  u. 
Gyn.,  1897.  vi,  571-608. 

Litzmann.     Die  Formen  ties  Beckons  nebst  einem  Anhange  Qber  die  Osteomalacic'.     Ber- 
lin, 1861. 
TJeber  die  hintere  Scheitelbeineinstellung.    Archiv  f.  Gyn.,  1871,  ii,  433-440. 
Die  Geburt  bei  engem  Becken.     Leipzig,  1884. 

LOhlein.     Erfahrungen  fiber  den  Werth  der  Castration  bei  Osteomalacic     Zeitschr.  f. 
Geb.  u.  Gyn..  1894.  xxix.  18-47. 

LunwiG  und  Savor.     Klin.  Bericht  fiber  die  Geburten  beiin  engen  Becken,  Berichl    aus 
■der  II  geb.-gyn.  Klinik  in  Wien.     Wien,  1897,  120-353. 

Michealis.     Das  enge  Becken.     Leipzig,  1851. 

MtiLLER.     Ueber  die  Prognose  der  Geburt  bei  engem  Becken.     Archiv  f.  Gyn.,  1896, 
xxvii,  311. 

Pinard.     Du  palper  mensurateur.     Traite  de  palper  abdominale,  2me  ed.,  Paris,  1889, 
'202-222. 
Note  pour  servir  a  l'histoire  de  la  puericulture  pendant  la  grossesse.     Annales  de  gyn. 
et  d'obst.,  1898,  1,  80-89. 

Rosenthal.     Die  "Wendung  und  Extraktion  bei  engem  Becken.    Arbeiten  aus  der  konigl. 
Frauenklinik  in  Dresden,  1893,  125-226. 

Piudaux.     De  la  rupture  de  la  symphyse  pubienne  au  cours  de  l'accouchement.    These  de 
Paris,  1898. 

Schauta.     Allg.  Pathologie  der  Beckenanomalien.     Mfiller's  Handbuch  der  Geb.,  1889, 
ii.  265-284  (full  literature). 
Die  Castration  bei  Osteomalacie.     Wiener  med.  Woehenschr.,  1900. 

Schoedel.     Erfahrungen  fiber  kfinstliche  Frfihgeburt,  etc.     Archiv  f.  Gyn.,  1901,  lxiv, 
151-164. 

Schroeder-Olshausex-Veit.     Lehrbuch  der  Geburtshulfe,  1899,  XIII.  Aufi.,  659. 

Schwartz.    Ueber  die  Haufigkeit  des  engen  Beckens.     Monatsschr.  f.  Geburtsk.,  1865, 
xxvi,  437-442. 

Simpson.     Memoir  on  Turning,  as  an  Alternative  for  Craniotomy  and  High  Forceps,  etc., 
1850. 
Selected  Obstetrical  and  Gynaecological  Works.  Edinburgh,  1871,  i,  393. 

Tarxier  et  Budix.      Traite  de  l'art  des  accouchements.     1898,  t.  iii,  70-135  (full  lit- 
erature). 

Valency.     De  l'accouchement  spontane  dans  les  bassins  retrecis  rachitiques.     These  de 
Paris.  1900. 

Varnier.     Accommodation  de  la  fete  fcetale  au  bassin  maternal.     L'obstetrique  jour- 
nalise, Paris,  1900.  131-149. 

Wilcke.     Das  Geburtsgewicht  der  Kinder  bei  engem  Becken.     Beitrage  zur  Geb.  u.  Gvn.. 
1901.  iv.  291-=302. 

Williams,  J.  W.     Pelvic  Indications  for  the  Performance  of  Csesarean  Section.     Amer- 
ican Medicine,  September  28,  1901. 

Winckel.     Behandlung  der  Osteomalacie.     Penzoldt  u.  Stintzing's  Handbuch  der  spec. 
Therapie.  v.  Abth.,  1896,  vii.  214-242  (full  literature). 
Ueber  die  Erfolge  der  Kastration  bei  der  Osteomalacie.     Volkmann's  Sammlung  klin. 
Vortrage,  N.  F.,  Xr.  28. 


CHAPTER    XXXVI 

ABNORMAL  PELVES  RESULTING    FROM  PRIMARY  ANOMALIES 

IN  DEVELOPMENT 

Three  separate  groups  of  cases  are  differentiated  according  as  trie  ab- 
normalities are:  (a)  Generalized  and  sym metrical;  (&)  localized  and  asym- 
metrical; (c)  localized  and  symmetrical. 

I.  Generalized  and  Symmetrical  Anomalies  in  Development. — Abnormal 
development  may  manifest  itself  in  an  excess  or  in  a  lack  of  the  general 
growth  of  the  pelvis.  In  the  former  case  we  have  to  do  with  the  generally 
enlarged  or  justo-major  pelvis,  and  in  the  latter  with  one  of  several  vari- 
eties— the  generally  contracted  (justo-minor)  pelvis,  the  infantile,  the  mas- 
culine, or  the  dwarf  type. 

The  Generally  Enlarged  {justo-major)  Pelvis. — This  variety  of  pelvis  is 
symmetrically  enlarged  in  all  its  parts,  and  differs  from  the  normal  only  by 
its  increased  size.  It  is  usually  observed  in  giantesses,  and  occasionally  in 
women  of  normal  stature;  indeed,  if  the  external  measurements  alone  are 
taken  as  a  criterion,  it  is  of  quite  frequent  occurrence  in  the  latter. 

According  to  Schauta,  the  various  diameters  in  this  type  rarely  exceed 
the  normal  by  more  than  2  centimetres,  though  he  refers  to  De  la  Tourette's 
case,  in  which  the  antero-posterior  and  transverse  diameters  of  the  superior 
and  inferior  straits  measured  14.9,  17,  and  14.9,  14.9  centimetres  re- 
spectively. In  not  a  few  cases  the  greatest  increase  is  in  the  antero-posterior 
diameter,  while  the  others  remain  practically  normal.  Occasionally  the 
enlargement  may  be  limited  to  the  superior  strait,  while  the  lower  portions 
of  the  pelvic  canal  retain  their  usual  proportions,  thus  producing  a  funnel- 
shaped  pelvis.  In  rare  instances  excessive  transverse  external  measure- 
ments may  be  due  to  the  fact  that  the  fossae  join  the  main  body  of  the 
iliac  bones  at  a  less  obtuse  angle  than  usual. 

This  variety  of  pelvis  has  no  effect  upon  the  course  of  labour,  except 
that  its  excessive  size  now  and  again  obviates  the  necessity  for  the  usual 
mechanism,  and  the  head  may  be  born  so  rapidly  and  suddenly  that  serious 
perineal  tears  result. 

Tlie  Generally  Contracted  {justo-minor)  Pelvis. — This  type  was  first  de- 
scribed by  Deventer  as  the  pelvis  nimis  parva,  while  Stein  later  applied 
to  it  the  designation  justo-minor.  All  of  its  measurements  are  more  or 
less  proportionately  shortened,  so  that  at  first  glance  the  pelvis  appears 
perfectly  normal,  the  narrowing  being  discovered  only  after  careful  men- 
suration. 


GENERALLY   CONTRACTED   PELVIS 


639 


As  a  rule,  the  generally  contracted  pelvis  is  lighter  in  texture,  and  its 
component  parts  are  more  delicately  formed  than  usual.  The  sacrum  is 
smaller,  and  the  alae  proportionately  shorter  than  the  bodies  of  its  verte- 
bra?. At  the  same  time  its  vertical  concavity  is  not  infrequently  increased. 
On  careful  examination  it  is  found  that  the  decrease  in  size  is  not  uniform, 


Fig.  543. 
Figs.  541-543. — Generally  Contracted  Pelvis. 

as  occasionally  the  conjugata  vera  is  relatively  shorter  than  the  transverse 
diameter  of  the  superior  strait,  and  exceptionally  the  inferior  is  relatively 
smaller  than  the  superior  strait,  so  that  we  have  a  type  approaching  the 
simple  flat  or  funnel-shaped  pelvis  respectively.  Michealis  considered  that 
the  antero-posterior  shortening  in  this  class  of  pelves  rarely  exceeds  1.5 
centimetre:  and,  although  this  appears  to  be  be  too  conservative  a  figure,  it 
may  be  said  that  whenever  the  conjugata  vera  measures  less  than  8  centi- 
metres, rhachitic  changes  should  be  suspected. 

This  pelvis  is  usually  met  with  in  small  women,  although  one  is  occa- 
sionally surprised  to  find  it  in  those  of  large  stature.  It  has  generally  been 
said  to  occur  but  rarely  in  Germany  and  France,  although  it  was  observed 
in  37  and  28  per  cent  of  the  contracted  pelves  reported  by  Miiller  and 


gin,    especially    in    negroes,    and 


640  OBSTETRICS 

Gonner  respectively;  and  Bichelet  states  that  it  is  much  more  common 
in  France  than  has  generally  been  believed.  Our  own  observations  show 
that  it  is  by  no  means  unusual  in  Baltimore,  as  it  was  noted  in  one  third 
of  the  contracted  pelves  occurring  in  white,  and  in  two  thirds  of  those 
occurring  in  black  women.  In  the  latter  it  is  undoubtedly  a  sign  of  de- 
generation, and  is  a  manifestation  of  the  imperfect  physical  development 
which  characterizes  negroes  living  in  large  cities. 

Miiller  considered  that  its  frequency  in  Berne  was  probably  due  to  the 
prevalence  of  cretinism  in  that  locality,  but  the  fact  that  Gonner  observed 

it  almost  as  frequently  in  Basel, 
where  the  latter  disease  occurs 
but  rarely,  militates  against  such 
a  view.  It  is  quite  possible  that 
not  a  few  so-called  justo-minor 
pelves  are  really  of  rhachitic  ori- 

that    in    such    cases    the    other 

Fig.  544,-Chondeodysteophia  Fcetalis.  more   characteristic   changes   are 

lacking. 

The  diagnosis  is  readily  made.  The  existence  of  a  generally  contracted 
pelvis  should  always  be  suspected  in  small  women,  and,  especially  in  poorly 
developed  working  women,  although  it  should  not  be  forgotten  that  it  may 
occur  in  large  and  apparently  well-formed  individuals.  -Accurate  informa- 
tion can  be  obtained  by  means  of  pelvimetry.  All  of  the  external  meas- 
urements are  considerably  and  uniformly  shortened.  Internal  examina- 
tion shows  a  shortened  conjugata  vera  with  general  smallness  of  the  pelvic 
cavity,  typical  rhachitic  changes  being  absent. 

The  effect  of  the  generally  contracted  pelvis  upon  labour  is  very  char- 
acteristic. Owing  to  the  fact  that  all  the  diameters  of  the  superior  strait 
are  shortened  instead  of  only  the  conjugata  vera,  as  in  flat  pelves,  the 
head  encounters  more  or  less  equal  resistance  from  all  sides  of  the  pelvic 
inlet,  and  consequently  enters  it  in  a  sharply  flexed  position,  so  that  on 
vaginal  examination  the  small  fontanelle  is  readily  felt,  whereas  the  large 
fontanelle  is  almost  or  quite  out  of  reach.  Moreover,  as  the  cantraction 
involves  all  portions  of  the  pelvic  canal,  labour  is  not  rapidly  completed 
after  the  head  has  passed  the  superior  strait,  and  as  a  rule  is  consider- 
ably prolonged.  This  is  due  partly  to  the  resistance  offered  by  the  pelvis, 
and  partly  to  the  faulty  character  of  the  uterine  contractions  incident  to 
the  imperfect  development  of  the  uterus,  which  frequently  characterizes 
such  cases. 

As  has  already  been  said,  a  generally  contracted  pelvis  with  a  conjugata 
vera  of  a  given  length  offers  a  greater  obstacle  to  labour  than  a  flat  pelvis 
offering  a  similar  measurement,  and  for  practical  purposes  half  a  centimetre 
must  be  added  to  the  latter  to  reduce  it  to  terms  of  the  former. 

The  Masculine  Pelvis.— Michealis  directed  attention  to  the  fact  that 
generally  contracted  pelves  are  occasionally  encountered  in  which  the  bones 
are  thicker  and  clumsier  than  usual  and  approach  the  male  type.  Pelves 
of  this  class  are  not  of  infrequent  occurrence,  and  have  the  same  effect  upon 


1>\YAKK    PKM'IS 


041 


Labour  as  the  ordinary  generally  contracted  variety,  though  in  exceptional 
instances  the  relative  contraction  of  the  interior  strait  may  give  rise  to 
serious  dystocia. 

The  Infantile  Pelvis. —  In  rare  instances,  as  the  result  of  disease,  which 
has  caused  the  individual  to  spend  her  entire  life  in  bed  without  attempt- 
ing to  sit  up  or  walk,  the  pelvis  retains  the  characteristic  infantile  form  to 
which  reference  was  made  in  Chapter  I.  Examples  of  this  abnormality 
have  been  described  by  Naegele,  Leisinger,  Buttner,  and  Gurlt,  but  natu- 
rally it  possesses  no  obstetrical  significance. 

The  Dwarf  Pelvis. — According  to  Breus  and  Kolisko,  several  varieties 
of  dwarfs  must  be  distinguished — i.  e.,  the  chondrodystrophic,  the  "true/' 
the  cretin,  the  rhachitic,  and  the  hypoplastic  dwarf. 

In  the  first-mentioned  variety  the  deformity  results  from  chondro- 
dystrophia  fcetalis  (Kaufmann),  achondroplasia  (Parrot  and  Porak),  or 
foetal  rhachitis,  as  the  disease  has  been  variously 
designated.  The  affection  is  not  allied  to  rha- 
chitis, but  is  characterized  by  well-marked 
changes  in  the  epiphyseal  cartilages  which  lead 
to  imperfect  development  of  the  shafts  of  the 
long  bones. 

In  the  "  true  "  dwarf  there  is  a  proportion- 
ate lack  of  general  development,  which  is  par- 
ticularly characterized  by  the  fact  that  the 
various  epiphyses  do  not  undergo  ossification, 
but  remain  cartilaginous  until  an  advanced  age. 

In  the  cretin  dwarf  the  lack  of  development 
is  general.  The  bony  changes  are  allied  to 
those  observed  in  the  true  dwarf,  but  are  less 
marked. 

The  term  rhachitic  divarf  should  not  be  ap- 
plied to  individuals  whose  short  stature  is  due 
to  skeletal  deformities,  but  should  be  restricted 
to  those  who  would  fall  far  below  the  normal 
height  even  if  the  deformities  were  straightened 
out  and  compensated  for. 

In  the  hypoplastic  dwarf  the  changes  are 
quantitative  instead  of  qualitative,  so  that  the 
individual  differs  from  the  normal  only  in  its 
miniature  appearance. 

Each  of  these  varieties  of  dwarfs  has  a  char- 
acteristically shaped  pelvis,  which  is  more  or 
less  generally  contracted. 

The  Chondrodystrophic  Divarf  Pelvis. — Fig. 
544  represents  a  chondrodystrophic  infant,  and  Fig.  545  a  chondrodys- 
trophic dwarf,  whose  pelvis  is  reproduced  in  Fig.  546.  This  specimen  was 
described  by  Breus  and  Kolisko,  and  was  obtained  from  a  woman  twenty- 
seven  years  old  and  123  centimetres  tall,  who  died  after  a  Cesarean  section. 

This  variety  of  pelvis  is  characterized  by  a  marked  antero-posterior  flat- 


- 


T 


Fig.  545. — Chondrodystrophic 
Dwarf  (Breus  and  Kolisko). 


642 


OBSTETRICS 


tening,  so  that  on  first  glance  one  might  believe  that  one  had  to  deal  with 
a  rhachitie  pelvis.  On  closer  examination,  however,  it  is  seen  that  the 
flattening  is  due  to  the  imperfect  development  of  the  portion  of  the  iliac 
bone  entering  into  the  formation  of  the  ilio-pectineal  line,  owing  to  which 
the  sacral  articulation  is  brought  much  nearer  the  pubic  bone  than  usual. 
In  6  pelves  of  this  character  described  by  Breus  and  Kolisko,  the  conjugata 
vera  varied  from  4  to  7  centimetres,  while  the  transverse  diameter  of  the 
superior  strait  was  but  slightly  shortened,  varying  from  11  to  12  centimetres. 
The  True  Dwarf  Pelvis  (Pelvis  Nana). — This  variety  of  pelvis  is  ex- 
tremely rare,   only  4  well-marked  specimens  being   in   existence — those 


Fig.  546. 
Figs.  546,  547. — Chondrodystrophy  Pelvis  (Breus  and  Kolisko). 


Fig.  547. 


described  by  Naegele  and  Boeckh,  Schauta,  Paltauf,  and  Breus  and  Kolis- 
ko, two  of  which  were  in  females.  The  pelvis  is  generally  contracted  and 
tends  towards  the  infantile  type,  but  its  most  characteristic  feature  is  the 
persistence  of  cartilage  at  all  the  epiphyses.  Thus,  in  Boeckh's  pelves, 
which  belonged  to  a  thirty-one-year-old  woman,  108  centimetres  tall,  the 
Y-shaped  cartilage  at  the  acetabulum  was  clearly  marked  and  the  sacral 
vertebra?  were  not  fused  together  (Fig.  548). 

The  Cretin  Dwarf  Pelvis. — This  is  a  generally  contracted  pelvis  with 
poorly  developed  and  imperfectly  formed  bones.  Unlike  that  of  the  true 
dwarf,  it  does  not  present  infantile  characteristics,  but  shows  signs  of  a 
steady  though  imperfect  growth  throughout  early  life.  Unossified  cartilage 
may  be  present  here  and  there  in  young  subjects,  but  it  disappears  with 
advancing  age  and  is  never  found  in  all  the  epiphyses  as  in  the  true 
dwarf  pelvis. 

The  Rhachitie  Dwarf  Pelvis. — True  rhachitie  dwarfs  are  rare,  and  possess 
generally  contracted,  flat  rhachitie  pelves,  which  do  not  differ  from  those 
described  in  the  previous  chapter  except  by  their  extremely  small  size. 

The  Hypoplastic  Dwarf  Pelvis. — According  to  Breus  and  Kolisko  this 
variety  of  pelvis  is  observed  in  very  small  individuals,  and  is  simply  a  nor- 


NAEGELE    PELVIS 


643 


mal  pelvis  in  miniature.  It  differs  materially  from  that  of  the  true  dwarf 
in  that  it  is  completely  ossified. 

II.  Localized  and  Asymmetrical  Anomalies  in  Development — The 
Obliquely  Contracted  or  Naegele  Pelvis. — Naegele,  in  1803,  was  the  first  to 

gnise  the  significance  of  this  variety  of  pelvis,  and  in  1839  published  a 
monograph  upon  the  subjed  based  upon  the  study  of  35  specimens,  one  of 
which  had  been  obtained  from  an  Egyptian  mummy. 

The  Xaegele  pelvis  presents  the  following  characteristics:  The  alae  of 
the  sacral  vertebrae  arc  either  lacking  or  imperfectly  developed  upon  one 
side,  while  the  corresponding  sacral  foramina  are  smaller  than  those  on  the 
normal  side.  In  the  great  majority  of  eases  the  sacrum  and  the  innomi- 
nate bone  are  thinly  synostosed  on  the  affected  side.  At  the  same  time  the 
latter  is  pushed  upward  and  backward  as  well  as  inward  from  the  region 
of  the  acetabulum,  and  its  crest  is  at  a  higher  level  than  that  of  its  fellow. 
The  ilio-pectineal  line  is  less  curved  than  normally,  being  almost  straight 
when  the  deformity  is  marked,  while  upon  the  opposite  side  its  curvature 
is  accentuated,  particularly  in  the  anterior  portion.  Corresponding  with 
the  change  in  position  of  the  innominate  bone,  the  ischial  tuberosity  and 


Fig.  :.4-. 
Figs.  54^.  54'.'.— Trie  Dwaef  Pelvis  (Boeckh). 


Tig.  549. 


spine  are  displaced  inward,  upward,  and  backward,  thereby  approaching  the 
outer  margin  of  the  sacrum  and  narrowing  the  sacro-sciatic  notch.  The 
symphysis  pubis  is  displaced  towards  the  well  side,  while  the  pubic  arch 
instead  of  looking  directly  forward  is  directed  towards  the  abnormal  side 
of  the  sacrum.  The  sacrum  itself  is  displaced  towards  the  ankylosed  side, 
while  its  anterior  surface  is  directed  more  or  less  obliquely  towards  it. 

As  a  result  of  these  changes  the  pelvis  becomes  obliquely  contracted, 
the  superior  strait  being  ovate  in  shape,  with  its  small  pole  directed  towards 
42 


644  OBSTETRICS 


the  abnormal  sacroiliac  joint  and  its  larger  end  towards  the  horizontal 
ramus  of  the  pubis  on  the  well  side.  Its  oblique  diameters  are  of  unequal 
length,  the  shorter  extending  from  the  sacro-iliac  synchondrosis  of  the 
well  side  to  the  ilio-pectineal  eminence  on  the  diseased  side,  while  the 
conjugata  vera  is  usually  somewhat  lengthened  and  is  directed  obliquely. 


Fig.  550.  Fig.  551. 

Figs.  550,  551. — Anterior  View  of  Obliquely  Contracted  Pelvis  (Naegele). 

The  distances  from  the  promontory  of  the  sacrum  to  the  acetabulum 
and  from  the  tip  of  the  sacrum  to  the  ischial  spine  are  markedly  diminished 
on  the  diseased  side.  At  the  same  time  the  distance  between  the  tuber 
ischii  of  the  diseased  side  and  the  opposite  posterior  superior  spine  is  less 
than  that  between  the  tuber  ischii  of  the  well  and  the  corresponding  spine 
of  the  diseased  side.  Moreover,  the  tip  of  the  spinous  process  of  the  last 
lumbar  vertebra  is  nearer  the  anterior  superior  spine  of  the  ilium  on  the 
diseased  than  on  the  well  side,  while  the  distance  from  the  lower  margin 
of  the  symphysis  to  the  posterior  superior  spine  is  less  upon  the  well  side. 

The  walls  of  the  pelvis  converge  below,  so  that  the  contraction  involves 
the  entire  pelvic  cavity  but  is  relatively  greater  in  the  plane  of  least 
pelvic  dimensions  and  the  inferior  strait  than  at  the  superior  strait.  The 
acetabulum  on  the  diseased  side  is  directed  more  anteriorly,  while  that  on 
the  well  side  looks  almost  directly  outward. 

Mode  of  Production. — The  genesis  of  this  variety  of  pelvic  deformity 
has  given  rise  to  a  great  deal  of  discussion,  some  writers  claiming  that 
the  defect  in  the  sacrum  is  primary  and  the  synostosis  secondary;  others, 
that  the  synostosis  results  primarily  from  changes  which  bring  about  more 
or  less  destruction  of  the  sacral  alas.  The  former  view  was  advocated 
particularly  by  Unna,  Hohl,  Litzmann,  Olshausen,  and  Schauta,  and  the 
latter  by  Betschler,  E.  Martin,  Thomas,  and  others. 


NAEGELE    PELVIS 


645 


It  is  now  generally  admitted  thai   the  first-mentioned  view  is  correct, 

! I. >h  1  ami  others  having  shown  that  the  entire  sacral  alas  might  be  lacking 
without  a  sign  of  synostosis.  Moreover,  Thomas  and  K  u  ml  rat ,  among  other 
observers,  nave  demonstrated  that  the  ahe  of  one  or  more  sacral  vertebrae 
may  he  absenl  or  imperfectly  developed  while  the  others  are  normal. 
Accordingly,  while  the  synostosis  usually  occurs  at  the  affected  sacro-iliac 
synchondrosis,  it  is  do1  a  accessary  characteristic  of  this  variety  of  pelvis. 

The  mechanism  by  which  the  deformity  is  produced  is  as  follows: 
Owing  to  the  asymmetry  of  the  sacrum  there  is  compensatory  scoliosis  of 
the  lumbar  portion  of  the  vertebral  column  with  its  convexity  on  the  dis- 
eased side.  This  causes  the  pelvis  to  assume  an  angle  with  the  horizon, 
thereby  bringing  about  a  towering  of  the  acetabulum  on  the  diseased  side. 
As  a  consequence  greater  pressure  is  exerted  by  the  femur  on  that  side, 
which  gradually  brings  about  an  upward,  backward,  and  inward  dis- 
placement of  the  corresponding  innominate  bone.  Owing  to  the  increased 
pressure,  the  synovial  membrane  at  the  sacro-iliac  synchondrosis  gradually 
undergoes  pressure  necrosis,  and  synostosis  eventually  results. 

Frequency. — Thomas,  in  1861,  was  able  to  collect  from  the  literature 
a  description  of  50  pelves  of  this  character.  Since  then  several  addi- 
tional cases  have  been  described,  but  at  present  the  entire  number  does 
not  exceed  100. 

Diagnosis. — Generally  speaking,  the  condition  is  readily  recognisable, 
provided  that  one's  attention  is  directed  to  the  possible  existence  of  such  a 


Fig.  552. — Posterior  View  of  Obliquely  Contracted  Pelvis  (Naegele). 


deformity.  Unfortunately,,  since  the  customary  external  measurements  give 
no  clew  to  its  presence,  the  diagnosis  is  usually  not  made  until  labour 
is  far  advanced,  when  the  evident  dystocia  forces  one  to  look  for  the 
cause.  The  patients  do  not  limp,  and  as  a  rule  give  no  history  sug- 
gestive of  trouble  at  the  sacro-iliac  joint.     On  the  other  hand,  the  ex- 


64:6 


OBSTETRICS 


istence  of  scoliosis,  a  variation  in  the  height  of  the  hips,  or  a  difference  in 
the  distance  between  the  spine  of  the  last  lumbar  vertebra  and  the  posterior 
superior  spines,  should  cause  one  to  suspect  its  possibility. 

Naegele  suggested  five  measurements  which  should  be  made  in  such 
cases:  (1)  From  the  tuber  ischii  of  one  side  to  the  opposite  posterior  supe- 
rior spine;  (2)  from  the  anterior  superior  spine  of  one  side  to  the  opposite 
posterior  superior  spine;  (3)  from  the  spine  of  the  last  lumbar  vertebra  to 
the  anterior  superior  spine  on  either  side;  (4)  from  the  trochanter  to  the 
opposite  posterior  superior  spine;  (5)  from  the  lower  margin  of  the  sym- 
physis pubis  to  the  posterior  superior  spines  on  either  side.  Normally, 
these  various  measurements  should  be  the  same  on  both  sides,  but  differ 
considerably  in  obliquely  contracted  pelves. 

Owing  to  the  difficulty  of  definitely  locating  their  end  points,  the  first, 
fourth,  and  fifth  measurements  are  rarely  employed;  but  the  information 
obtained  from  the  second  and  third  is  of  very  considerable  value.  A  differ- 
ence of  more  than  1  centimetre  between  these  measurements  on  the  two 
sides  indicates  an  obliquely  contracted  pelvis,  but  is  not  sufficient  to 
enable  one  to  differentiate  between  the  Naegele  and  the  other  varieties. 
On  internal  examination  the  conjugata  vera  is  not  shortened,  but  on  meas- 
uring the  diagonal  conjugate  it  is  found  that  the  symphysis  pubis,  instead 
of  being  situated  directly  in  front  of  the  promontory,  lies  considerably  to 


Fig.  553.  Fig.  554. 

Figs.  553,  554. — Transversely  Contracted  Eobert  Pelvis  (Eobert). 

one  side  of  it.  On  palpation  it  is  found  that  the  lateral  wall  of  the  pelvis, 
as  well  as  the  ischial  spine  and  tuberosity,  approaches  the  sacrum  much 
more  closely  on  the  diseased  than  on  the  opposite  side,  while  the  ilio-pec- 
tineal  line  is  markedly  flattened.  At  the  same  time  the  distance  between  the 
tubera  ischii  is  markedly  diminished. 

Effect  upon  Labour. — When  the  deformity  is  at  all  pronounced,  the  side 
of  the  pelvis  corresponding  to  the  small  end  of  the  oval  is  so  contracted  as 
to  be  of  no  practical  value  for  the  passage  of  the  child,  so  that  engagement, 
if  it  is  to  occur  at  all,  must  take  place  on  the  opposite  side.    In  effect,  the  pel- 


NAKtiKLE    PELVIS 


617 


vie  in  1< '1  becomes  converted  into  one  of  the  generally  contracted  variety,  and 
an  idea  of  its  available  space  is  gained  by  measuring  not  the  conjugate  vera, 
birl  the  distance  between  the  symphysis  pubis  and  the  sacro-iliac  synchon- 
drosis on  the  normal  side.  If  engagement  is  possible,  labour  will  progress 
more  favouraoly  when  the  occipui  is  directed  towards  the  ilio-pectineal 
eminence  of  the  diseased  than  Inwards  that  of  the  well  side,  for  the  rea- 


Fig.  555. 
Figs.  555,  556. — Split  Pelvis  (Breus  and  Kolisko). 

son  that  in  the  first  instance  the  biparietal  diameter  lies  in  the  long  oblique 
instead  of  in  the  short  oblique  diameter  of  the  superior  strait. 

Owing  to  the  steady  increase  of  the  contraction  in  the  lower  portion 
of  the  pelvis,  marked  difficulty  is  experienced  when  the  head  attempts  to 
pass  between  the  ischial  spines  and  tuberosities,  and  the  possibility  of 
delivery  depends  upon  the  distance  between  these  points. 

Prognosis.- — If  the  deformity  is  marked  the  prognosis  is  bad,  unless 
Cassarean  section  be  performed.  Litzmann  states  that  22  out  of  28  mothers 
died  in  the  first  labour,  and  that  only  6  labours  ended  spontaneously  out  of 
the  41  making  up  his  entire  series. 

Generally  speaking,  spontaneous  labour  is  out  of  the  question  unless 
the  short  oblique  diameter  measures  8.5  centimetres.  "When  this  limit  is 
reached,  Ca?sarean  section  is  the  only  rational  method  of  treatment  if  the 
child  is  alive  and  the  patient  in  good  condition.  Pinard  in  1  case  per- 
formed a  modified  symphyseotomy,  which  he  designated  as  ischio-piibiotomy, 
and  thereby  gained  sufficient  room  for  the  delivery  of  the  child.  He 
sawed  through  the  horizontal  ramus  of  the  pubis  and  the  ascending  ramus 
of  the  ischium  on  the  diseased  side  instead  of  cutting  through  the  symphy- 
sis. The  operation  is  strongly  condemned  by  Budin,  and  its  performance 
is  certainlv  not  to  be  recommended. 


618 


OBSTETRICS 


III.  Localized  and  Symmetrical  Anomalies  in  Development. — These 
may  be  of  several  characters:  (a)  Imperfect  development  of  both  sacral 
alse;  (b)  lack  of  union  at  the  symphysis  pubis;  (c)  lack  of  development  of 
the  vertebral  bodies  of  the  sacrum;  (d)  assimilation  of  the  last  lumbar 


Fig.  557. — Contracted  Pelvis  Due  to  Absence  of  Bodies  of  Sacral  Vertebra  (Litzmann). 

vertebra  with  the  sacrum,  or  of  the  first  sacral  vertebra  with  the  lumbar 
column. 

The  Transversely  Contracted  or  Robert  Pelvis. — Imperfect  development 
of  the  sacral  alee  on  both  sides  produces  a  pelvis  which  is  markedly  con- 
tracted transversely;,  and  is  sometimes  described  as  the  double  Naegele  pelvis. 
This  variety  is  extremely  rare,  Tarnier  stating  that  only  10  cases  had  been 
described  up  to  1898  (Fig.  553). 

In  the  pelvis  described  by  Eobert  the  alse  on  both  sides  of  the  sacrum 
were  lacking,  and  the  innominate  bones  firmly  synostosed  with  the  rudi- 
mentary sacrum.  The  anterior  surface  of  the  latter  was  convex  in  both 
directions.  Owing  to  the  imperfect  development  of  the  sacrum,  the  pelvis 
was  markedly  contracted  transversely,  and  only  slightly  antero-posteriorly, 
the  antero-posterior  and  transverse  diameters  of  the  superior  and  inferior 
straits  measuring  9.7  and  7,  and  10.6  and  5.1  centimetres  respectively. 

Just  as  in  the  Naegele  pelvis,  bony  union  between  the  sacrum  and 
innominate  bones  is  not  an  essential  characteristic,  and  is  occasionally 
lacking,  sometimes  on  one,  much  more  rarely  on  both  sides.  Where  there 
is  a  difference  in  the  development  of  the  alas  on  the  two  sides  it  can  readily 
be  understood  how  an  asymmetrically  transversely  contracted  pelvis  may 
result. 

The  diagnosis  is  readily  made,  all  of  the  transverse  external  measure- 
ments being  markedly  shortened  while  the  external  conjugate  remains 
practically  normal.     Internal  examination  shows  the  conjugata  vera  to  be 


SIM. IT    PELVIS 


649 


only  slightly  changed,  while  it  is  hardly  possible  for  the  marked  approach 
of  the  ischial  spines  and  tuberosities  to  one  another  to  escape  recognition. 
In  all  rases  thus  far  reported  the  transverse  narrowing  of  the  pelvis  was 
so  great  as  absolutely  to  preclude  the  possibility  <>!'  the  birth  of  a  living 
child,  and  accordingly  Cesarean  section  is  the  only  rational  method  of 
treatment. 

Split  Pelvis. — In  rare  instances  union  between  the  pubic  bones  at  the 
symphysis  does  aol  occur,  and  the  anterior  portions  of  the  pelvis  gape  widely 
(Fig.  555).    This  condition  is  usually  associated  with  ectopia  of  the  bladder 


Fig.  559 


Fig.  560. 
Figs.  558-560. — High  Assimilation  Pelvis. 


and  imperfect  development  of  the  lower  portion  of  the  anterior  abdominal 
wall.  It  has  been  observed  in  adults,  but  naturally  is  more  common  in 
young  children.  TTe  are  indebted  to  Litzmann  for  the  first  accurate  de- 
scription of  a  pelvis  of  this  character  from  an  obstetrical  point  of  view. 


650 


OBSTETRICS 


In  the  split  pelvis,  owing  to  descent  of  the  promontory  of  the  sacrum 
and  the  absence  of  union  at  the  symphysis,  there  is  marked  transverse 


Vi 


Fig.  561.  Fig.  562. 

Figs.  561,  562. — Transversely  Contracted  Assimilation  Pelvis  (Breus  and  Kolisko). 

widening  of  the  posterior  portion  of  the  pelvis,  while  its  anterior  portions 
are  more  or  less  parallel.  External  examination  in  such  cases  shows  a 
marked  flaring  of  the  anterior  superior  spines  of  the  ilium,  and  were  the 
defective  condition  of  the  anterior  portion  of  the  pelvis  not  clearly  evident 
a  rhachitic  pelvis  might  be  suspected. 


Fig.  563. — Low  Assimilation  Pelvis  (Breus  and  Kolisko). 

The  distance  between  the  extremities  of  the  pubic  bones  varies  consider- 
ably, and  occasionally  is  as  great  as  14  centimetres.    This  space  is  usually 


ASSIMILATION    PELVIS 


651 


filled  by  a  fibrinous  band.  Schickele  has  Lately  reported  a  case  of  labour  in 
a  pelvis  of  this  character,  ami  states  that  S  others  are  to  be  found  in  the 
literature.  In  only  2  of  them  was  labour  perfectly  spontaneous,  but  in 
nunc  of  them  was  great  difficulty  experienced,  as  for  practical  purposes  the 
pelvis  may  be  considered  as  generally  enlarged,  the  dystocia  being  due  to 
abnormalities  of  mechanism  resulting  from  the  absence  of  a  resistant  ante- 
rior pelvic  wall.  Breus  and  Kolisko  give  an  excellent  description  of  several 
hitherto  undescribed  cases,  and  discuss  fully  the  mechanical  factors  con- 
cerned in  their  product  ion. 

Imperfect  Development  of  the  Vertebral  Bodies  of  the  Sacrum. — Litzmann 
lias  described  a  remarkable  pelvis,  in  which  almost  the  entire  sacrum  was 
lacking.  This  defect  was  associated  with  considerable  transverse  contrac- 
tion, which  increased  as  the  inferior  strait  was  approached,  the  transverse 
diameter  of  the  superior  strait  measuring  10.5  centimetres,  while  the  dis- 


Fig.  oiil — Asymmetrical  Assimilation  Pelvis  (Breus  and  Kolisko). 


tance  between  the  ischial  spines  and  ischial  tuberosities  was  6.5  and  8.5 
centimetres  respectively  (Fig.  557). 

Assimilation  Pelvis. — Occasionally  the  transverse  processes  of  the  last 
lumbar  vertebra  may  be  transformed  into  structures  similar  to  the  lateral 
masses  of  the  sacral  vertebra?.  Hence  the  former  assumes  the  functions  of 
the  first  sacral  vertebra,  the  sacrum  being  now  composed  of  6  instead  of  5 
pieces.  In  other  instances  the  first  sacral  vertebra  may  take  on  the  charac- 
teristics of  a  lumbar  vertebra  and  be  assimilated  with  the  lumbar  column,  so 
that  there  are  6  lumbar  and  only  d  sacral  vertebra?.  Occasionally  the  first 
coccygeal  vertebra  may  become  assimilated  with  the  sacrum,  but  this  has  no 
effect  upon  the  character  of  the  pelvis.    With  the  exception,  then,  of  the 


652  OBSTETRICS 

last,  these  conditions  give  rise  to  marked  changes  in  the  shape  of  the 
pelvis. 

When  the  last  lumbar  is  assimilated  with  the  first  sacral  vertebra,  so  that 
the  sacrum  consists  of  6  pieces,  important  changes  in  the  shape  of  the 
pelvis  result,  which  depend  in  great  part  upon  the  manner  in  which  the 
sacrum  and  innominate  bones  articulate,  as  well  as  upon  the  width  of  the 
former.  In  some  cases  the  condition  gives  rise  to  a  pelvis  which  is  very 
high  in  its  posterior  portion,  and  whose  superior  strait  is  almost  round,  the 
walls  in  its  inferior  portion  converging,  thus  producing  a  funnel-shaped 
pelvis  (see  Fig.  558).  In  other  cases  the  condition  gives  rise  to  a  some- 
what transversely  contracted  pelvis  (see  Fig.  561). 

On  the  other  hand,  when  the  first  sacral  vertebra  is  assimilated  with  the 
lumbar  column,  a  pelvis  results  which  is  very  shallow  in  its  posterior  por- 
tion, but  which  offers  no  particular  obstacle  to  labour  (see  Fig.  563). 

Occasionally  the  assimilated  vertebra  may  undergo  only  a  partial 
change,  one  side  of  it  retaining  the  characteristics  of  a  lumbar  or  sacral 
vertebra,  as  the  case  may  be,  while  the  other  side  undergoes  considerable 
modification.  Under  such  circumstances  asymmetrical  pelves  result  which 
are  not  infrequently  obliquely  contracted  (see  Fig.  564). 

LITERATURE 

Betschler.     Neue  Zeitschr.  f.  Geb..  1840,  ix,  121. 

Boeckh.     Ueber  Zwergbecken.     Archiv  f.  Gyn.,  1893,  xliii,  847-472. 

Breus  und  Kolisko.     Die  path.  Beckenformen,  1900,  i.     Spaltbeeken,  107-139.     Assirai- 

lationsbecken,  169-256.     Zwergbecken,  259-366. 
Budix.     Recherches  experimentales  a  propos  de Tisehio-pubiotomie.    Feromes  en  couches 

et  nouveau-nes,  1897,  468-482. 
Buttxer.     Bescbreibung  des  inneren  Wasserkopfs  und  des  ganzen  Beinkorpers  einer  von 

ihrer  Geburt  an  bis  im  31.  Jahr  krank  gewesenen  Person  weiblichen  Geschlechts. 

Konigsberg,  1873. 
Devexter.     Neues  Hebammenlicht.     II.  Aufl.,  1728,  196. 

Gonner.     Zur  Statistik  der  engen  Becken.     Zeitschr.  f.  Geb.  u.  Gyn.,  1882,  vii,  314-331. 
Gurlt.     Ueber  einige  Missgestaltungen  des  weiblichen  Beckens.     Berlin,  1854. 
Hohl.     Das  schrag  verengte  Becken.     Leipzig,  1852. 

Kaufmaxx.     Untersuchungen  ilber  die  sogenannte  fotale  Rachitis.     Berlin.  1892. 
Kundrat.     Quoted  in   full  by  Breus  and  Kolisko.     Die  path.   Beckenformen,   1900,  i, 

147-153. 
Leisixger.     Anat.  Bescbreibung  eines  kindlichen  Beckens.     D.  I.,  Tubingen,  1847. 
Litzmaxx.     Das  schragovale  Becken.     Kiel.  1853. 

Das  gespaltene  Becken.     Archiv  f.  Gyn..  1872,  iv.  266-284. 

Ein  durch  mangelhafte  Entwickelung  des  Kreuzbeines  querverengtes  Becken.     Archiv 

f.  Gyn.,  1885,  xxv,  31-39. 
Martix,  E.     De  pelvi  oblique  ovate.     June,  1841. 
Muller.     Zur  Erequenz  u.  Aetiologie  des  allg.  verengten  Beckens.    Archiv  f.  Gyn.,  1880, 

xvi,  155-173. 
Naegele.     Das  schrag  verengte  Becken.     Mainz,  1839. 

Olshausex.     Schragverengtes  Becken,  etc.     Monatsschr.  f.  Geburtsk.,  1862,  xix,  161-185. 
Paltauf.     Quoted  in  full  by  Breus  and  Kolisko. 
Pinard.     De  Pischio-pubiotomie  ou  operation  de  Farabeuf.     Annales  de  gyn.  et  d'obst., 

1893,  xxxix,  139-143. 


PRIMARY    A  NOMA  I.IKS   IX    PELVIC   DEVELOPMENT  653 

Porak.     De  l'athondroplasie.     Nbu v.  archives  d'obst.  el  de  gyn.,  decembre,  1889. 

Richelet.     Du  bassin  generalement  n'ln'ci,  etc.    These  de  Paris,  1896. 

Robert.     Beschreibung  eines  im  hfichsten  Grade  querverengten  Beckens,  etc.     Karlsruhe 

ii.  Freiburg,  Is  12. 
Schauta.    Die  Beckenanoraalien.    Muller's  Handbuch  der  Geb.,  1889,  ii,  220-496. 

Das  durch  mangelhafte  Entwickelung  eines  Kreuzbeinfliigels  schriigverengten  Becken. 

Miller's  Handbuch  der  Geb.,  1889.  ii,  319-331. 
Die   Beckenformen  bei  symmetrischen   and  asymmetrischen  Assimilation.    Miiller's 

Handbuch  der  Geb.,  1889,  ii,  447-458. 
Schick  kle.     Beitrag  zur  Lehre  des  normalen  und  gespaltenen  Beckens.    Beitrage  zur 

Geb.  ii.  Gyn.,  1901,  iv,  243-272. 
Stein.     Lehre  der  Geburtshulfe,  etc.,  1825,  i,  78. 

Tarniee  et  Budix.     Traite  de  Tart  des  accouchernents,  1898,  iii,  314-318. 
Thomas,  S.     Das  schragverengte  Becken,  etc.     Leipzig.  1861. 
L'.nxa.     Zur  Genese  des  schriigverengten  Beckens.     Hamburger  Zeitschr.  f.  die  ges.  Med., 

1843,  xxiii,  281. 


CHAPTEE    XXXVII 

PELVIC  ANOMALIES  DUE   TO  DISEASE   OF   THE    VERTEBRAL 

COLUMN 

Kyphotic  Pelvis. — Kyphosis  or  humpback,  the  result  of  spinal  caries, 
plays  an  important  part  in  the  production  of  pelvic  abnormalities,  for  when 
situated  in  the  lower  portion  of  the  vertebral  column  it  is  nearly  always 
associated  with  a  characteristically  funnel-shaped  pelvis. 

We  are  indebted  to  Bokitansky  for  the  first  accurate  work  upon  the 
subject,  although  as  early  as  1759  Madame  Boursier  de  Coudray  reported  a 
Caesarean  section  performed  upon  a  patient  having  a  pelvis  of  this  character. 


Fig.  565. — Longitudinal  Section  through  Pelvis  and  Spinal  Column  in  Dorso-lumbar 
Kyphosis  (Breus  and  Kolisko). 

The  most  important  contribution  to  our  knowledge  concerning  the 
kyphotic  changes  was  made  by  Breisky  (1865),  who  clearly  set  forth  the 
mechanical  factors  by  which  the  alteration  in  shape  was  brought  about. 
Later  Chantreuil,  Champneys,  Barbour,  Treub,  and  particularly  Breus  and 
Tvolisko,  added  materially  to  our  knowledge  of  the  subject. 
654 


KYPHOTIC    PELVIS 


655 


The  effed  exerted  upon  the  pelvis  by  kyphosis  differs  according  to 
iis  Location.  When  the  gibbus  or  hump  is  situated  in  the  dorsal  region  it  is 
usually  compensated  for  by  marked  lordosis  hciicat h  it,  so  that  the  pelvis 
itself  is  Iml  Little  changed.  On  the  other  hand,  when  situated  at  the  junc- 
tion of  the  dorsal  and  lumbar  portions  of  the  vertebral  column  its  effect 
upon  bhe  pelvis  becomes  manifest,  and  is  still  further  accentuated  when 
the  kyphosis  is  lower  down,  being  most  marked  when  it  is  at  the  Lumbo- 
sacral junction. 

Klien  analyzed  85  cases  reported  in  the  literature,  and  found  that  the 
kyphosis  was  dorso-lumbar  in  24,  lumbar  in  17,  and  lumbo-sacral  in  37 


Fig.  566. — Kyphotic  Pelvis,  showing  Elongation  of  Conjugata  Vera. 


cases,  while  in  7  other  cases  the  vertebral  column  so  overhung  the  superior 
strait  as  to  produce  a  "  pelvis  obtecta  "  (Fig.  567). 

The  characteristic  feature  of  the  kyphotic  pelvis  is  a  retropulsion  and 
rotation  of  the  sacrum,  by  which  the  promontory  becomes  displaced  back- 
ward" and  the  tip  forward.  At  the  same  time  the  entire  bone  becomes 
elongated  vertically^  ancTnarrowed  from  side  to  side.  These  changes  are 
associated  with  a  rotation  of  each  innominate  bone  about  an  axis,  which 
extends  through  the  symphysis  pubis  and  the  sacro-iliac  articulation,  so 
that  the  iliac  fossae  become  flared  outward  while  the  lower  portions  of  the 
ischial  bones  are  turned  toward  the  middle  line. 

When  the  kyphosis  is  in  the  dorso-lumbar  region,  marked  lordosis  below 
it  indicates  an  attempt  at  compensation,  but  as  this  is  imperfect,  the  body 
weight  is  transmitted  to  the  sacrum  in  such  a  manner  that  the  latter  be- 
comes markedly  retroposed  and  lengthened,  its  promontory  being  farther 


656 


OBSTETRICS 


Fig.  567. — Pelvis  Obtecta  (Fehling). 


backward  and  at  a  higher  level  than  usual.  At  the  same  time  its  normal 
vertical  concavity  is  replaced  by  a  straight  or  even  convex  surface,  while  its 
lateral  concavity  becomes  obliterated  by  the  projection  of  the  vertebral 
bodies  beyond  their  alas.  The  bodies  themselves  are  considerably  narrower 
than  usual,  and  the  alas  of  the  first  sacral  vertebra  appear  to  be  drawn  out 
and  to  extend  obliquely  upward  to  the  promontory. 

Owing  to  its  backward  displacement,  the  posterior  surface  of  the  sa- 
crum approaches  the  superior  posterior  spines,  thereby  relaxing  the  ilio- 

sacral  ligaments.  At  the 
same  time  the  posterior 
extremities  of  the  innom- 
inate bones  are  pushed 
apart,  and  as  a  conse- 
quence their  upper  por- 
tions tend  to  rotate  out- 
ward and  the- lower  por- 
tions inward,  so  that  the 
crests  are  flared  out  and 
are  situated  at  a  lower 
level  than  usual,  while 
the  ischial  spines  and 
tuberosities  approach  the 
middle  line.  This  move- 
ment of  rotation  is  still 
further  accentuated  by  the  increased  tension  exerted  by  the  ilio-femoral 
ligaments  resulting  from  a  diminution  of  the  pelvic  inclination.  The  ace- 
tabula  also  are  shifted  slightly  and  look  more  to  the  front  than  usual.  Co- 
incident with  the  displacement  of  the  sacrum,  the  ilio-pectineal  line  be- 
comes longer,  particularly  in  its  iliac  portion. 

These  changes  give  rise  to  a  funnel-shape^elyjs^  in  which,  as  the  result 
of  the  marked  increase  in  the  length  of  ffieconjugata  vera,  the  superior 
strait  becomes  round  or  oval  in  shape,  with  the  long  diameter  running 
antero-posteriorly,  while  the  transverse  diameter  remains  unchanged  or  may 
even  be  somewhat  shorter  than  usual.  There  is  also  a  gradual  diminution 
of  all  the  antero-posterior  diameters  of  the  pelvis  below  the  superior  strait, 
but  the  most  characteristic  change  is  the  shortening  of  the  various  trans- 
verse diameters,  especially  between  the^ischial  spines,  and  to  a  somewhat 
less  extent  between  the  ischial  tuberosities.  The  pelvic  inclination  is  usu- 
ally decreased,  though  in  some  cases  it  is  only  slightly  altered. 

In  18  kyphotic  pelves  described  by  Breus  and  Kolisko,  the  conju- 
gata  vera  varied  from  10.7  to  16.5  centimetres  in  length,  the  distance  be- 
tween the  spines  from  5.2  to  8.2  centimetres,  and  that  between  the  ischial 
tuberosities  from  6  to  12.1  centimetres.  At  the  same  time  it  should  be 
remembered  that  in  not  a  few  cases  the  entire  cavity  is  smaller  than  usual, 
Klien  having  pointed  out  that  30  per  cent  of  all  the  kyphotic  pelves  de- 
scribed were  also  generally  contracted,  so  that  a  comjugata  vera  which  at' first 
glance  appears  normal  may  in  reality  be  relatively  increased  in  length. 
When  the  kyphosis  is  situated  at  the  junction  between  the  last  lumbar 


KY 


BEOTIC   PELVIS 


657 


and  the  first  sacral  vertebrae,  the  pelvic  changes  are  generally  more  marked 
than  those  just  described,  as  the  promontory  of  the  sacrum  is  usually  cari- 


r--.^ 


DkV 


Fig.  56S. — Diagram  showing  Forces  concerned  in  the  Production  of  Kyphotic  Pelvis 

(Tarnier). 

ous  and  takes  part  in  the  formation  of  the  gibbus.  In  such  cases  there 
can  be  no  attempt  at  compensation,  as  the  body  weight  is  transmitted 
directly  to  the  anterior  surface  of  the  sacrum,  so  that  its  upper  part  is 
pushed  far  backward.  It  is  not  lengthened,  and  its  alas  are  usually  very 
small.  In  such  cases  the  transverse  contraction  becomes  still  more  marked, 
so  that  the  distance  between  the  ischial  spines  may  be  reduced  to  3  or  -I  centi- 
metres, as  in  the  cases  described  by  Schroeder  and  Doktor.  The  pelvic 
inclination  is  always  diminished,  and  in  some  cases  is  entirely  obliterated. 
When  the  kyphosis  is  very  marked,  the  lumbar  vertebrae  may  so  over- 
hang the  superior  strait  as  effectively  to  prevent  the  child's  head  from  en- 


658  OBSTETRICS 

tering  it.  This  condition  was  described  by  Fehling  as  pelvis  obtecta.  In  his 
specimen  the  distance  between  the  symphysis  pubis  and  the  nearest  point 
on  the  vertebral  column  was  3.8  centimetres.  The  pelvis  obtecta  was 
noted  in  8  per  cent  of  the  cases  analyzed  by  Klien.  A  similar  condition  was 
described  by  Herrgott  as  spp-ndylizeme. 

Mode  of  Production. — A  kyphosis  m  the  dorsal  region  is  usually  com- 
pensated for  by  a  marked  lordosis  below  it,  so  that  the  body  weight  is 
transmitted  to  the  sacrum  in  the  usual  manner.  On  the  other  hand,  as 
Breisky  pointed  out,  when  the  hump  is  situated  lower  down  the  body 
weight  is  transmitted  through  its  upper  limb,  and  on  reaching  the  gibbus 
becomes  resolved  into  two  components,  one  of  which  is  directed  down- 
ward and  the  other  backward.  This  latter  force  draws  the  promontory  of 
the  sacrum  backward  and  upward,  thus  leading  to  rotation  of  the  en- 
tire bone  (Fig.  568). 

Breus  and  Kolisko  have  shown  that,  owing  to  the  necrosis  of  one  or 
more  of  the  vertebral  bodies  forming  the  gibbus,  the  body  weight  is  not 
transmitted  directly  through  the  vertebral  bodies  below  it,  but  through 
their  arches  and  spinous  processes.  As  a  result  the  latter  come  into  close 
contact,  while  the  anterior  portions  of  the  vertebra?  become  widely  sepa- 
rated, thus  leading  to  marked  lordosis  beneath  the  gibbus.  This  causes 
an  upward  drag  upon  the  bodies  of  the  sacral  vertebra?,  which  become 
stretched  and  elongated.  Coincident  with  these  changes  the  innominate 
bones  likewise  undergo  rotation,  which  brings  about  a  narrowing  of  the 
lower  portion  of  the  pelvis,  and  is  due  partly  to  the  backward  displace- 
ment of  the  sacrum  and  partly  to  increased  tension  exerted  by  the  ilio- 
femoral ligaments. 

Frequency. — According  to  Klien's  statistical  study  a  kyphotic  pelvis  is 
met  with  once  in  every  6,016  labours,  although  he  himself  believes  that 
this  estimate  was  too  low,  in  view  of  the  fact  that  humpbacked  women  are 
relatively  numerous.  On  the  whole,  it  is  probable  that  any  one  who  has 
much  obstetric  practice  is  liable  to  meet  with  one  or  more  cases  complicated 
by  this  abnormality. 

Diagnosis. — The  diagnosis  is  usually  easy,  as  the  external  deformity  is 
readily  detected  and  at  once  suggests  the  possible  existence  of  a  funnel- 
shaped  pelvis. 

External  pelvimetry  is  of  great  value,  as  it  shows  that  the  distance 
between  the  iliac  crests  is  equal  to  or  exceeds  that  between  the  trochanters, 
whereas  normally  the  reverse  is  true.  In  a  patient  suffering  from  this  de- 
formity, lines  drawn  through  the  iliac  crests  and  trochanters  will  meet 
somewhere  in  the  neighbourhood  of  the  feet,  instead  of  near  the  head  as 
is  generally  the  case. 

On  internal  examination  the  transverse  narrowing  of  the  pelvic  outlet 
should  be  noted,  as  well  as  the  antero-posterior  lengthening  of  the  conjugata 
vera.  In  the  lumbo-sacral  variety  the  promontory  no  longer  exists,  and  the 
bodies  of  the  lower  lumbar  vertebra  overhang  the  superior  strait.  Accord- 
ingly, particular  attention  should  be  devoted  to  estimating  the  length  of  the 
"pseudo-conjugate  " — the  distance  from  the  upper  margin  of  the  symphy- 
sis  pubis  to  the  nearest  portion  of  the  vertebral  column.     Occasionally 


KYPHOTIC    PKLVIS 


659 


the  condition  may  ho  confounded  with  spondylolisthesis,  and  the  differ- 
ential diagnosis  will  be  considered  under  the  latter  heading. 


i 


Fig.  569. — Front  and  Side  View  of  Patient  with  Limbo-sacral  Kyphosis  (Hirst). 

Effect  upon  Labour. — Owing  to  the  collapse  of  the  vertebral  column 
the  ribs  approach  the  pelvic  brim  and.  markedly  lessen  the  capacity  of  the 
abdomen,  which  m  consequence  "becomes  markedly  pendulous  atTan  early 
period  of  pregnancy,  these  mechanical  conditions  favouring  the  occurrence 
of  certain  abnormal  positions  of  the  foetus.  Thus  Klien,  in  103  cases, 
found  100  longitudinal  and  3  oblique  presentations.  Of  the  former  90 
were  vertex,  4  face,  and  6  breech  presentations. 

It  is  interesting  to  note  that  left  occipito-iliac  anterior  presentations 
occurred  much  less  frequently  than  usual,  being  noted  in  only  one  third  of 
the  cases,  while  the  remainder  were  equally  divided  between  right  anterior 
and  posterior  presentations.  It  is  difficult  to  give  a  satisfactory  explanation 
for  the  unusual  frequency  of  the  E.  0.  I.  A.  position,  but  the  production 
of  posterior  positions  is  readily  seen  to  he  due  to  the  pendulous  abdomen, 
as  under  such  circumstances  the  concave  anterior  surface  of  the  child 
tends  to  apply  itself  to  the  convex  anterior  surface  of  the  uterus. 

At  the  time  of  labour  the  presenting  part  experiences  no  difficulty  in 
entering  the  superior  strait,  and  no  obstacle  is  met  with  until  it  reaches 
the  lower  part  of  the  pelvis,  particularly  between  the  ischial  spines.  If 
the  transverse  contraction  be  not  too  marked  to  prevent  the  passage  of 
the  head,  further  difficulty  is  encountered  when  the  latter  attempts  to  pass 
43 


660  OBSTETRICS 

beneath  the  pubic  arch,  which,  owing  to  the  approach  of  the  tubera  ischii, 
has  become  more  angular  than  usual,  so  that  the  head  is  prevented  from 
coming  in  contact  with  the  lower  margin  of  the  symphysis  pubis  and  must 
descend  lower  than  usual  in  order  to  be  born.  This  fact  readily  explains 
tin?  deep  pen'npa.1  t.pa.ra  so  frequently  observed. 

Generally  speaking,  it  may  be  said  that  when  the  distance  between  the 
/schial  spines  is  less  than  8.5  centimetres,  labour  becomes  difficult  or  impos- 
sible, according  to  the  degree  of  contraction.  Owing  to  the  narrowing  of 
the  pubic  arch,  occipitoanterior  are  less  favourable  than  occipito-posterior 
presentations,  as  in  the  former  the  wide  biparietal  diameter  has  to  accom- 
modate itself  to  the  narrow  pubic  arch,  whereas  in  the  latter  its  place 
is  taken  by  the  brow.  According  to  Ivlien,  face  presentations  are  still  more 
favourable  for  the  same  reason. 

Prognosis. — If  the  contraction  is  at  all  marked,  the  prognosis  is  bad 
unless  Csesarean  section  is  resorted  to.  Klien  has  analyzed  the  histories 
of  175  labours  occurring  in  95  women,  and  found  that  40  per  cent  of  the 
children  died.  The  maternal  mortality  varied  according  to  the  degree  of 
contraction;  when  the  disproportion  between  the  biparietal  diameter  of  the 
child's  head  and  the  distance  between  the  spines  was  slight  it  was  6.2  per 
cent,  as  compared  with  17  per  cent  in  marked  cases. 

Neugebauer  has  likewise  analyzed  the  histories  of  199  labours  occurring 
in  118  women,  and  found  that  only  44  ended  spontaneously.  The  maternal 
mortality  was  24.3  per  cent,  and  49  per  cent  of  the  foetuses  died. 

Treatment. — When  the  distances  between  the  spines  and  tuberosities  of 
the  ischium  do  not  fall  below  8  centimetres,  spontaneous  labour,  or  at  least 
a  probable  delivery  with  forceps,  can  be  looked  for,  but  when  the  meas- 
urements fall  below  this  limit,  operative  interference  becomes  necessary. 
If  the  case  be  seen  in  the  later  weeks  of  pregnancy,  the  propriety  of  the 
induction  of  premature  labour  may  be  considered.  As  a  rule,  however, 
Cesarean  section  at_term  js  far  preferable  unless  the  child  is  very  small. 
Symphyseotomy  is  urged  by  many  as  an  appropriate  operation  in  this  class 
of  deformity,  and  will  certainly  give  a  sufficient  increase  in  the  size  of  the 
pelvic  outlet  to  permit  the  passage  of  the  head,  provided  the  distance  be- 
tween the  spines  does  not  fall  below  6  centimetres.  If  the  child  is  already- 
dead,  craniotomy  is  the  operation  of  election. 

Kypho-EhachTtic  Pelvis. — Kyphosis  is  nearly  always  of  carious  origin, 
but  when  due  to  rhachitis  it  is  usually  associated  with  a  greater  or  lesser 
degree  of  scoliosis.  In  the  rare  cases  of  pure  rhachitic  kyphosis,  how- 
ever, the  pelvic  changes  are  slight,  as  the  effect  of  the  kyphosis  is  counter- 
balanced to  a  great  extent  by  those  of  the  rhachitis,  the  former  leading  to 
an  elongation  and  the  latter  to  a  shortening  of  the  conjugata  vera,  while 
tending  respectively  to  narrow  and  widen  the  inferior  strait.  Thus  it  may 
happen -that  a  woman  presenting  a  markedly  deformed  vertebral  column 
of  this  character  may  still  have  a  practically  normal  pelvis.  The  two  pro- 
cesses, however,  do  not  always  counteract  one  another,  and,  as  a  rule,  when 
the  kyphosis  is  high  up  the  pelvic  changes  are  predominantly  rhachitic. 

Scoliotic  Pelvis. — Pronounced  scoliosis,  or  lateral  curvature  of  the  spine, 
is  usually  of  rhachitic  origin;  but,  on  the  other  hand,  minor  degrees  of  the 


SCOLIOTIC    PELVIS 


661 


deformity  are  often  observed  «  hich  have  no  connection  with  rickets.  When 
the  scoliosis  involves  the  upper  portion  of  the  vertebral  column  it  is 
usually  compensated  for  by  a  corresponding  curvature  in  the  opposite  direc- 
tion lower  down,  thus  giving  rise  to  a  double  or  S-shaped  curve.  In  such 
cases  the  body  weighl  is  transmitted  to  the  sacrum  in  the  usual  manner. 
Bui  when  the  scoliosis  is  Lower  down  and  involves  the  lumbar  region,  the 
sacrum  takes  part  in  the  compensatory  process  and  accordingly  assumes  an 
abnormal  position  which  leads  to  slight  asymmetry  of  the  pelvis. 

Breus  and  Kolisko  have  devoted  particular  attention  to  the  pelvic 
anomalies  resulting  from  non-rhachitic  scoliosis,  but  the  changes  in 
shape  are  usually  so  slight  as  to  have  little  or  no  effect  upon  the  course 
of  labour. 

When  due  to  rhachitis,  the  scoliosis  may  be  very  pronounced,  and 
give  rise  to  marked  pelvic  deformity,  in  which  the  characteristic  changes 


Fig.  570.  Fig.  571. 

Figs.  570.  571. — Obliquely  Contracted  Pelvis,  Due  to  Xox-khachitic  Scoliosis 
CBreus  and  Kolisko"). 


due  to  the  anomaly  of  the  vertebral  column  are  superadded  to  those  result- 
ing from  rhachitis.  In  such  cases  the  scoliotic  convexity  is  usually  direct- 
ed to  the  right  side,  as  -was  noted  in  7  out  of  the  9  cases  described  by 
Leopold. 

Under  such  circumstances  the  sacrum  takes  part  in  the  compensatory 
scoliosis,  one  side  being  compressed  and  the  other  elongated,  so  that  its 
long  axis  becomes  directed  obliquely  towards  one  side.  At  the  same  time 
it  undergoes  a  partial  rotation  about  its  vertical  axis,  the  spinous  pro- 


662 


OBSTETRICS 


cesses  being  directed  towards  the  compressed  side,  a  result  which  indicates 
the  abnormal  direction  along  which  the  body  weight  is  transmitted  to  the 
iliac  bone,  and  thence  to  the  femur.  Owing  to  the  abnormal  pressure 
exerted  upon  one  side,  the  pelvis  becomes  obliquely  contracted,  usually 
upon  the  side  corresponding  to  the  lumbar  convexity;  but,  owing  to  the 
coexistence  of  rhachitic  changes,  the  contraction  is  in  great  part  limited 
to  the  superior  strait. 


Fie:.  573. 


Figs.  572,  573. — Scolio-rhachitic  Pelvis  (Tarnier). 


Owing  to  the  pressure  exerted  upon  the  compressed  side  of  the  sacrum, 
anjiilpsis  at  the  sacro-iliac  articulations  often  occurs.     At  the  same  time 
the  innominate  bone  on  the  affected  side  is  displaced  upward,  inward,  and 
backward,  while  its  acetabulum  looks  more  forward  than  usual.     The  sym- 
physis pubis  is  brought  somewhat  nearer  to  the  opposite  side,  and  owing 
to  the  rhachitic  changes  the  pubic  arch   is   widened,  while   the   tubera 
ischii  are  directed  outward  instead  of  inward  as  in  the  Naegele  pelvis.    In 
marked  cases  the  superior  strait  assumes  an  obliquely  ovate  appearance,  and 
occasionally  the  acetabulum  on  the  affected  side  may  come  almost  in  con- 
tact with  the  promontory. 
/  (        The  location  of  the  contraction  can  be  determined  by  external  examina- 
I  Jtion,  as  it  always  lies  upon  the  side  towards  which  the  convexity  of  the 
i  '  scoliosis  is  directed.     The  contracted  side  is  valueless  from  an  obstetrical 
*    standpoint,  and  for  practical  purposes  the  suneriej^strait  ^becomes  generally 
narrowed.     If,  however,  the  head  manages  to  pass  through  it,  no  further 
difficulty  is  experienced  in  its  downward  course,  owing  to  the  rhachitic 
widening  of  the  lower  portion  of  the  pelvis. 


KYI'MO-SCOLIO-HMACIHTIC    PELVIS 


663 


Kypho-Scoliotic  Pelvis. — The  distort  inn  of  the  pelvis  will  vary  accord- 
ing as  the  kyphosis  or  the  scoliosis  is  the  predominant  factor  in  th< 
funnily  of  the  spinal  column.  When  the  former  is  more  pronounced,  the 
pelvis  will  partake  of  the  kyphotic  character,  and  vice  versa.  When  the 
two  deformities  are  approximately  equal,  however,  the  kyphotic  changes 
in  the  pelvis  predominate,  although  the  influence  of  the  scoliosis  tends 
to  counteract,  to  a  certain  extent,  the  transverse  narrowing  of  the  infe- 
rior strait. 

Kypho-Scolio-Rhachitic  Pelvis.— This  variety  of  pelvic  deformity  has 
been  studied  more  particularly  by  Leopold  and  Barbour.  As  has  already 
been  pointed  out,  a  kyphosis  due  to  rhachitis  is  nearly  always  complicated 
by  a  scoliosis,  and  the  latter  nearly  always  predominates  in  the  production 
of  pelvic  deformity,  for  the  reason  that  the  kyphosis  and  the  rhachitis  tend 
mutually  to  counteract  one  another  in  their  effect  upon  the  pelvis.  Ac- 
cordingly, the  resulting  pelvis  does  not  differ  materially  from  that  observed 
in  scolio-rhachitis,  except  that  the  tendency  to  antero-posterior  flattening 
is  partially  counteracted  by  the  action  of  the  kyphotic  vertebral  column. 
Nevertheless,  owing  to  the  presence  of  the  scoliosis,  the  oblique  deformity  of 


"^^         Fig.  574.  Fig 

Figs.  574,  575. — Kypiio-Scoliotic-Kiiachitic  Pelvis  (Leopold). 


the  superior  strait  is  usually  quite  marked.  Generally  speaking,  how- 
ever, this  class  of  pelvis  is  more  favourable  from  an  obstetrical  standpoint 
than  that  due  to  scolio-rhachitis  alone. 

Spondylolisthetic  Pelvis. — The  term  spondylolisthesis  (from  o--6vSv\os, 
vertebra,  and  oAto-^o-ts,  slipping  or  sliding)  was  introduced  by  Ivilian  in 
1853,  in  describing  a  pelvis  in  which  the  last  lumbar  vertebra  had  become 
displaced  downward  over  the  anterior  surface  of  the  sacrum. 

The  degree  of  displacement  may  vary  greatly.    When  the  deformity  is 


66± 


OBSTETRICS 


slight  the  anterior  inferior  margin  of  the  last  lumbar  vertebra  merely  pro- 
jects a  short  distance  beyond  the  anterior  margin  of  the  promontory  of  the 
sacrum,  while  in  pronounced  cases  the  entire  body  of  the  vertebra  is  dis- 
placed downward  and  forward  into  the  pelvic  cavity,  so  that  its  inferior  sur- 
face comes  in  contact  with  and  more  or  less  completely  covers  the  body  of  the 
first,  and  occasionally  that  of  the  second  sacral  vertebra.  As  a  consequence, 
a  greater  or  lesser  portion  of  the  lumbar  column  comes  to  occupy  the 
upper  portion  of  the  pelvic  cavity,  the  superior  strait  assuming  a  reni- 
form  shape. 

The  lower  lumbar  vertebras  may  overhang  the  pelvic  inlet  to  such  an 
extent  that  the  obstetrical  or  pseudo-conjugate  will  be  represented  by  a 
line  drawn  from  the  upper  margin  of  the  symphysis  to  the  lower  margin  of 
the  fourth,  third,  or  even  second  lumbar  vertebra,  as  the  case  may  be.    In 

the  specimen  described  by  me  in 
1899  the  pseudo-conjugate  extended 
to  the  lower  margin  of  the  third  lum- 
bar vertebra  and  measured  6.5  centi- 
metres, as  compared  with  a  distance 
of  7.6  centimetres  to  the  lower  mar- 
gin of  the  fourth  lumbar. 

The  displacement  of  the  last  lum- 
bar vertebra  is  due  not  to  luxation, 


Fig.  576. — Vertical  Section  through  Spondy 
lolistiietic  Pelvis  (Kiliau). 


but  to  the  lengthening  and  bending 
of  its  interarticular  portions.  Its 
inferior  articular  processes  still  re- 
tain their  normal  relation  to  the  su- 
perior articular  processes  of  the  first 
sacral  vertebra,  whereas  its  body  and 
its  superior  articular  processes,  to- 
gether with  the  rest  of  the  vertebral 
column,  become  displaced  forward 
and  eventually  downward.  As  a  re- 
sult of  the  new  position  assumed  by 
the  body  of  the  last  lumbar  vertebra, 
the  superior  and  anterior  surfaces  of 
the  promontory  become  more  or  less  worn  away  by  friction,  the  defect  being 
not  infrequently  followed  by  ankylosis  which  definitely  checks  further  dis- 
placement. In  advanced  cases  the^Hiferior  articular  processes  of  the  last 
lumbar  and  the  superior  articular  processes  of  the  first  sacral  vertebra  are 
usually  firmly  synostosed  together,  as  are  also  the  inferior  articular  processes 
of  the  fourth  and  the  superior  articular  processes  of  the  fifth  lumbar  ver- 
tebra. 

Owing  to  the  collapse  of  the  vertebral  column  into  the  pelvic  cavity, 
the  centre  of  gravity  falls  in  front  of  instead  of  just  behind  the  acetabula, 
and  consequently  the  pelvis  must  be  tilted  backward  in  order  that  the 
individual  may  retain  an  upright  position.  In  other  words,  the  pelvic 
inclination  must  be  diminished,  and  when  the  deformity  is  marked  the 
plane  of  the  superior  strait  becomes  parallel  to  the  horizon.     This  is  ren- 


SPONDYLOLISTHETIC    I'KLVIS 


065 


dered  possible  by  changes  in  the  ilio-femoral  ligaments,  which  are  mani- 
fested on  the  one  hand  by  a  marked  roughening  of  the  portions  of  the 


Fig.  578.  Fig.  579. 

Figs.  577-579. — Spondylolisthetic  Pelvis. 


pelvis  to  which  they  are  attached,  and  on  the  other  by  characteristic  changes 
in  gait  of  the  patient.  In  my  own  case  the  pelvic  inclination  was  obliter- 
ated; but,  had  it  remained  normal,  the  vertebral  column  would  have  formed 
a  right  angle  with  the  legs,  necessitating  the  patient's  going  upon  all-fours, 
whereas,  as  a  matter  of  fact^  she  was  able  to  walk  erect. 

As  the  inferior  surface  of  the  last  lumbar  vertebra  is  in  contact  with 
"the  anterior  instead  of  the  superior  surface  of  the  first  sacral  vertebra,  the 
action  of  the  body  weight  tends  to  force  .the  promontory  of  the  sacrum 
backward,  thereby  causing  it  to  rotate  about  its  transverse  axis,  while  its 
tip  approaches  the  anterior  pelvic  wall.  The  retropulsion  and  rotation  of 
the  sacrum,  together  with  the  increased  traction  exerted  by  the  ilio-femoral 
ligaments,  causes  each  innominate  bone  to  rotate  about  an  axis  extending 
from  the  symphysis  to  the  sacro-iliac  joint,  and  tends  to  give  the  pelvis 
a  funnel  shape,  just  as  in  kyphosis,  the  inferior  strait  becoming  consider- 
*ab"ly  contracfed  transversely  and  the  pubic  arch  narrowed. 


G66 


OBSTETRICS 


JEtiology. — Kilian  considered 
vertebra  was  rendered  possible  by 


iwmm 


mul 


Fig.  580. — Spondylolisthesis  ;  Vertical 
Section  through  Last  Three  Lumbar 
Vertebra  and  Sacrum.     X  %■ 


Fig.  581. — Fourth  and  Fifth  Lumbar 
Vertebrae  from  my  Case  of  Spondylo- 
listhesis.    X  )4- 

A,  superior  articular  process ;  B,  transverse 
process ;  C,  inferior  articular  process ;  D, 
lamina  of  fourth  lumbar  vertebra;  E, 
superior  articular  process ;  F,  inferior 
articular  process ;  G,  transverse  process ; 
if,  I,  J,  fissures  in  interarticular  portion 
of  last  lumbar  vertebra. 


that  the  displacement  of  the  last  lumbar 
inflammatory  softening  of  the  interverte- 
bral disk.  Later,  various  hypotheses  were 
advanced  as  to  its  mode  of  production. 
Robert,  Lambl,  and  Konigstein  showed 
that  the  displacement  could  not  take 
jDlace  so  long  as  the  inferior  articular  pro- 
cesses of  the  last  lumbar  were  normal  and 
in  contact  with  the  superior  articular  pro- 
cesses of  the  first  sacral  vertebra,  unless- 
the  entire  vertebra  became  lengthened. 

Neugebauer  devoted  thirteen  years 
(1882-'95)  to  the  study  of  this  subject, 
and  during  that  period  published  15 
journal  articles  and  3  monographs  upon 
it,  covering  nearly  900  pages,  not  to 
mention  the  discussions  and  demonstra- 
tions in  which  he  took  part.  He  showed 
conclusively  that  in  the  vast  majority  of 
cases  the  deformity  was  rendered  possi- 
ble by  a  lengthening  and  thinning  out 
of  the  interarticular  portions  of  the  last 
lumbar  vertebra,  by  which  its  superior 
and  interior rarticular  processes  become 
separated  by  a  long,  thin  lamina  of  bone 
instead  of  being  almost  in  the  same  ver- 
tical line  (Fig.  581). 

This  condition  he  attributed  to  Lm- 
perfect  cleveloprnpnt  of  the  interarticu- 
lar  portion  (spondylolysis)  or  to  its  frac- 
ture, with  subsequent  stretching  of  the 
callus.  He  considered  that  the  former 
was  the  more  frequent  cause,  as  he  was 
able  to  demonstrate  it  in  many  verte- 
bras which  presented  no  signs  of  spondy- 
lolisthesis. When  the  displacement  is 
marked  the  interarticular  jDortion  is  not 
only  lengthened  and  thinned  out,  but 
also  becomes  bent  over  the  jn'omontory 
of  the  sacrum,  thus  forming  a  dolicho- 
Jcyrto-platy-spondylus. 

In  opposition  to  Neugebauer's  state- 
ment that  the  deformity  always  results 
from  changes  in  the  interarticular  por- 
tion, Chiari  definitely  showed,  in  one 
case  at  least,  that  it  can  follow  fracture 
of  the  articuli 


:pcesses   without  the 
characteristic  changes  in  the  vertebra. 


SPONDYLOLISTHETIC   PELVIS 


667 


Arbuthnol  Lane  stated  thai  the  disease  is  more  common  than  is  gener- 
ally supposed,  as  he  observed  several  examples  of  it  in  coal-heavers.  He 
considers  thai  in  such  cases,  at  least,  the  changes  in  the  interarticular  por- 
tion are  due  not  to  abnormalities  in  development  but  to  excessive  pressure, 
which  results  from  carrying  heavy  burdens.  Complete  literature  upon 
the  subject  will  be  found  in  my  own  article  and  in  that  of  Breus  and 
Kolisko. 

Frequency. — Neugebauer,  in  1893,  was  able  to  collect  115  cases  of  spon- 
dylolisthesis, most  of  which  were  clinical  observations.  In  1899  the  author 
collected  123  cases,  6.5  per  cent  of  which  occurred  in  males.     Accord- 


'»*»! 


i 


> 


Fig.  582. — Fkont  and  Back  Views  of  Woman  with  Spondylolisthesis  (Ahlfeld). 


ing  to  Breus  and  Kolisko  only  20  indisputable  anatomical  specimens 
of  this  condition  are  in  existence,  2  of  which  they  described  for  the 
first  time. 

Effect  upon  Labour. — "When  the  condition  is  but  slightly  marked  its 
effect  upon  labour  is  similar  to  that  of  a  .flat  pelvis,  astlie  greatest  con- 
traction is  in  the  conjugata  vera,  although  it  should  be  remembered  that 
it  is  likewise  associated  with  considerable  contraction  of  the  inferior  strait. 
When  the  deformity  is  pronounced  and  the  lower  lumbar  vertebrae  over- 
hang the  superior  strait,  the  degree  of  contraction,  from  an  obstetrical 
point  of  view,  is  to  be  reckoned  not  by  the  distance  between  the  sym- 
physis pubis  and  the  anterior  portion  of  the  last  lumbar  vertebra,  but  by  the 
length  of  the  pseudo-conjugate,  whose  posterior  extremity  may  be  at  the 


668 


OBSTETRICS 


fourth,  third,  or  even  second  lumbar  vertebra,  and  in  many  cases  is  so 
short  as  absolutely  to  preclude  the  possibility  of  the  head  entering  the 
pelvis. 

Diagnosis. — In  typical  cases,  mere  inspection  of  the  patient  should  lead 
one  to  suspect  the  existence  of  this  deformity,  inasmuch  as  there  is  always 
marked  lumbar  lordosis  and  the  entire  trunk  seems  to  have  caved  in,  so 
that  the  "ribs  come  almost  in  contact  with  the  iliac  crests.  When  viewed 
from  the  front,  the  abdominal  walls  appear  redundant  out  of  all  propor- 
tion.    Such  patients  have  a  peculiar  duck-like  walk  or  waddling  gait,  to 

which  Neugebauer  first  directed  atten- 
tion. Since  the  posterior  portion  of  the 
last  lumbar  vertebra  retains  its  normal 
position  while  the  rest  of  the  vertebral 
column  sinks  forward,  the  spine  of  the 
last  lumbar  vertebra  will  .sometimes 
form  a  marked  prominence  just  above 
the  sacrum.  The  condition,  however, 
should  not  be  mistaken  for  a  deep-seat- 
ed kyphosis. 

On  internal  examination  the  diagno- 
sis, as  a  rule,  is  readily  made,  as  the  body 

of  the  last  lumbar  vertebra  will  be  found 
■> 

lying  in  front  of  the  anterior  and  upper 
portion  of  the  sacrum  and  will  be  de- 
tected when  one  attempts  to  measure  the 
diagonal  conjugate.  At  the  same  time 
the  ilio-pectineal  line  ends  abruptly  at 
the  margins  of  the  overhanging  vertebral 
body  instead  of  continuing  uninterrupt- 
edly to  the  promontory  of  the  sacrum. 

Owing  to  the  marked  lordosis,  which 
frequently  accompanies  the  condition, 
the  bodies  of  the  lower  lumbar  vertebra? 
can  readily  be  palpated  and  counted,  and 
the  bifurcation  of  the  aorta,  or  at  least 
the  common  iliac  arteries,  are  not  infre- 
quently readily  accessible  to  the  exam- 
ining finger. 

Occasionally  pronounced  rhachitic 
changes  in  the  sacrum  may  simulate 
spondylolisthesis,  but  a  correct  diagnosis  can  usually  be  arrived  at.  If 
such  patients  be  anaesthetized,  on  careful  palpation  the  ilio-pectineal  lines — 
will  be  found  toterminate  at  the  promontory^of  the  sacrum  instead  of  at 
the  sides  ofThlTprolapsed  body  ol  the  last  lumbar  vertebra". 

A  somewhat  similar  condition  is  presented  in  marked  cases  of  lumbo- 
sacral k}rphosis,  particularly  in  the  pelvis  obtecta.  Under  such  circum- 
stances the  promontory  of  the  sacrum  is  destroyed,  but  a  correct  diagnosis 
ean  usually  be  macleTby  carefrtHy-  palpating  the  anterior  surface  of  the 


]Tig.  583.  —  Side  View  of  "Woman  with 
Spondylolisthesis,  showing  Project- 
ing Spine  of  Last  Lumbar  Vertebra. 


SPONDYLOLISTHETIC   PELVIS  669 

sacrum  and  tracing  the  alse  to  the  body  of  the  firsl  sacral  vertebra,  which,  of 

course,  is  impossible  in  spondylolisthesis. 

Prognosis. — Generally  speaking,  spontaneous  labour  can  occur  only 
when  the  deformity  is  minimal,  and  accordingly,  in  pronounced  cases,  the 
outlook  is  uniformly  bad  for  both  mother  and  child  unless  radical  opera- 
tive measures  be  undertaken.  Other  things  being  equal,  a  spondylolisthetic 
pelvis  offers  a  worse  prognosis  than  a  rhachitic  one  with  the  same  antero- 
posterior measurements,  for  the  reason  that  in  the  former  the  inferior  strait 
is  contracted,  while  in  the  latter  it  is  usually  enlarged. 

In  considering  the  probable  outcome  of  labour,  one  should  not  only 
measure  the  distance  between  the  symphysis  pubis  and  the  last  lumbar 
vertebra,  but  should  also  estimate  the  pjgejAdo-conjugate.  inasmuch  as  the 
latter  much  more  frequently  than  the  antero-posterior  diameter  of  the  supe- 
rior strait  offers  the  greatest  obstacle  to  labour.  The  fact  that  a  patient  with 
spondylolisthesis  has  had  one  or  more  spontaneous  labours  does  not  neces- 
sarily imply  that  the  labour  in  question  will  be  uneventful,  for  the  reason 
that  the  degree  of  deformity  not  infrequently  increases  with  age.  as  was 
clearly  demonstrated  in  my  own  case. 

Treatment. — "With  a  pseudo-conjugate  of  8  centimetres  or  over,  the  pos- 
sibility of  spontaneous  labour,  or  delivery  by  torceps  or  version,  should  be 
borne  in  mind:  but  when  it  measures  less  than  £  r-P-ntimPtvPQ  Cesarean  sec- 
tion  should  be  done  at  the  onset  of  labour.  Symphyseotomy  does  not  seem 
applicable  to  the  condition.  It  certainly  proved  ineffectual  in  Morisani's 
case  as  well  as  in  my  own.  having  been  resorted  to  in  the  latter  only  after 
the  patient  had  persistently  declined  to  submit  to  Ca?sarean  section. 


LITERATURE 

P)ARbour.     Spinal  Deformity  in  Relation  to  Obstetrics.     Edinburgh,  1883. 
Boursier  de  Coudray.  Louise.     Abrege  de  Tart  des  aecouchements.     Paris,  1759. 
Breiskt.     Ueber  den  Einfluss  der  Kyphose  anf  die  Beckengestalt.     Zeitsehr.  der  Ge- 

sellsch.  der  Aerzte  in  TVien,  i.  I860. 
Breus  und  Kolisko.     Die  path.  Beckenfonnen.  Bd.  iii.  I.  Theil.  1900.     Spondylolisthesis, 

17-159.     Kyphosen-Beeken,   163-307.     Skoliosen-Beeken.   311-352.     Kyphoskoliosen 

Becken,  355-359. 
Champxeys.     The  Obstetrics  of  the  Kyphotic  Pelvis.     Trans.  Lond.  Obst.  Soc,  1883,  xxv, 

166-194. 
Chaxtreuil.     Etude  sur  les  deformations  du   bassin   chez  les  cyphotiques.     These  de 

Paris.  1869. 
C'hiari.     Die  Aetiologie  und  Oenese  der  sogenannten  Spondylolisthesis  lumbo-sacralis. 

Zeitsehr.  f.  Heilkunde.  1892. 
Doktor.    Ein  Fall  Yon  conservativen  Kaiserschnitt.     Centralbl.  f.  Gym.  1893.  630-633. 
Fehlixg.     Pelvis  obtecta.     Archiv  f.  Gym,  1872.  iv.  1-33. 
Herrgott.     Du  spondylizeme.     Archives  de  Tocologie,  1877  ( Fev.-^fars). 
KrLiAX.      De   spondylolisthesi   gravissima?    pelvangustire    causa   nuper   detecta.      Bonn, 

1853. 
Kliex.     Die  Geburt  beim  kyphotischen  Becken.     Archiv  f.  Gym.  1896.  1.  1-128. 
Koxigsteix.     Entstehungsweise  spondylolisthetischer  Becken.     D.  L.  Marburg.  1871. 
Lambl.     Das  Wesen  und  die  Entstehung  der  Spondvlolisthesis.     Scanzoni's  Beitrlige, 

1855.  iii.  1-77. 


670  OBSTETRICS 

Lane.     Some  of  the  Changes  which  are  produced  by  Pressure  in  the  Lower  Part  of  the 

Spinal  Column ;  Spondylolisthesis,  etc.     Trans.  Lond.  Path.  Soc,  1885,  xxxvi,  364- 

378. 
Leopold.     Das  skoliotische  und  kypho-skol.  rachitische  Becken.     Leipzig,  1879. 
Weitere  Untersuchungen  iiber  das  skoliotische  mid  kypho-skol.  rachitische  Becken. 

Archiv  f.  Gyn.,  1880,  xvi,  1-23. 
Morisani.     Ancora  della  Sinfisiotomia.     Annali  di  Ost.  e  Gin.,  1886,  viii,  345-391. 
Neugebauer.     Zur   Entwiekelungsgeschichte  des    spondylolisthetischen    Beckens    und 

seiner  Diagnose.  Halle  u.  Dorpat,  1882,  294. 
Spondylolisthesis  et  spondylizeme.  Paris,  1892. 
Die  heutige  Statistik  der  Geburten  bei  Beckenverengerung  infolge  von  Riickgrats- 

kyphose.     Monatsschr.  f.  Geb.  u.  Gyn.,  1895,  1,  317-347. 
Robert.     Eine  eigenthumliche  angeborene  Lordose,  etc.     Monatsschr.  f.  Geburtsk.,  1855, 

v,  81-94. 
Rokitansky.     Anomalien  der  Gestalt  des  Riickgriits  und  seiner  Theile.     Lehrbuch  der 

path.  Anat.,  III.  Aufl.,  1856,  ii,  162-172. 
Schroeder-Olshausen-Veit.     Lehrbuch  der  Geb.,  XIII.  Aufl.,  1899,  649.     • 
Treub.     Recherches  sur  le  bassin  cyphotique.     Leyden,  1889. 
Williams,  J.  Whitridge.     A  Case  of  Spondylolisthesis,  with  Description  of  the  Pelvis. 

Amer.  Jour.  Obst.,  1899,  xl,  145-171. 


CHAPTER    XXXVIII 

PELVIC  ANOMALIES  RESULTING  FROM  THE  ABNORMAL  DIREC- 
TION OF  THE  FORCE  EXERTED  BY  THE  FEMORA— ATYPICAL 
DEFORMITIES 

Normally,  in  the  case  of  an  individual  standing  erect,  the  upward  and 
inward  force  exerted  by  the  femora  is  of  equal  intensity  on  either  side,  and 
is  transmitted  to  the  pelvis  through  the  acetabula.  In  walking  or  running, 
the  entire  body  weight  is  transmitted  alternately  first  to  one  and  then 
to  the  other  leg.  On  the  other  hand,  in  a  person  suffering  from  disease 
affecting  one  leg,  the  other  sound  one  has  to  bear  more  than  its  share  of 
the  body  weight,  and  consequently  the  upward  and  inward  force  exerted 
by  the  femur  is,  as  a  rule,  greater  upon  that  side  of  the  pelvis.  To  these 
mechanical  factors  are  due  the  changes  in  shape  which  accompany  certain 
forms  of  lameness,  provided  that  the  lesion,  which  gives  rise  to  the  latter, 
appears  at  an  early  period  of  life  while  the  pelvic  bones  are  still  in  a 
formative  state. 

The  defect  may  be  either  unilateral  or  bilateral;  in  the  former  case 
it  is  usually  due  to  coxalgia,  luxation  of  the  fprrmr.  infantile  paralysis, 


Fig.  5S4. — Diagram   showing  Coxalgic  Pel- 
vis   BEFORE    THE    INDIVIDUAL    HAS     \V.\LKEI) 

( Tarnier). 


Fig.  585. — Diagram  showing  Coxalgic  Pel- 
vis after  the   Individual   has  Walked 
Tarnier). 


or  shortening  of  one  leg  from  various  causes,  while  the  most  common  causes 
of  the  latter  are  luxation  of_both  femora  and  double  club-foot.  These 
conditions  have  been  studied  in  detail  by  T^rouvost,  in  whose  article,  as 
well  as  in  the  chapter  of  Tarnier  and  Budin  upon  the  subject,  full  litera- 
ture is  to  be  found. 

671 


672 


OBSTETRICS 


Pelvic  Deformities  Due  to  Unilateral  Lameness. — Coxalgia  occurring  in 
early  life  nearly  always  gives  rise  to  an  obliquely  contracted' pelvis.  If  the 
disease  makes  its  appearance  before  the  patient  learns  to  walk,  or  if  the  child 
is  obliged  to  keep  to  its  bed  for  a  prolonged  period,  definite  changes  occur 
in  the  pelvis  as  a  direct  result  of  the  disease.     These  are  in  great  part 


Fig.  588. 
Figs.  586-588. — Coxalgio  Pelvis  with  Ankylosed  Femur. 


atrophic,  and  are  manifested  by  imperjgct  development  of  the  diseased 
side  of  the  pelvis,  the  innominate  bone  being  smaller  than  its  fellow  and 
the  ilio-pecfmeal  7ine  represented  by  the  arc  of  a  circle  having  a  smaller 
radius  than  upon  the  well  side.  At  the  same  time,  the  sacral  alas  are 
less  developed  upon  the  affected  side,  and  the  entire  bone  is  somewhat 
rotated  about  its  vertical  axis,  so  that  its  anterior  surface  looks  towards 
the  well  side  (Figs.  584  and  585). 

When  the  individual  begins  to  stand,  owing  to  the  actual  shortening  of 
the  diseased  leg  or  to  fear  of  placing  it  firmly  upon  the  ground,  the  body 
weight  is  transmitted  in  great  part  to  the  well  leg.  As  a  result  the  pelvis 
becomes  obliquely  tilted,  being  higher  on  the  well  side,  and  a  compensa- 
tory scoliosis  appears.  At  the  same  time  the  upward  and  inward  force  ex- 
erted by  the  femur  tends  to  push  the  well  side  of  the  pelvis  upward,  inward, 
and  backward,  whereby  the  ilio-pectineal  line  is  markedly  flattened  and 


PKLY1C   ANOMALIES   DLTK  TO    UNILATERAL    LAMENESS 


673 


the  asymmetry  of  the  sacrum  still  further  increased,  thus  giving  rise  to 
an  obliquely  contracted  pelvis^  The  contraction  is  not  limited  to  the 
superior  strait,  but  involves  the  lower  portion  of  the  pelvis  as  well,  the 
gpine  and  tuberosity  of  the  ischium  being  displaced  towards  the  middle  line. 

Not  uncommonly  these  changes  are  accompanied  by  irritative  processes 
at  the  sacro-iliac  articulations,  which  eventually  lead  to  ankylosis.  As 
a  general  rule,  the  oblique  contraction  is  to  be  found  on  the  well" side 
of  the  pelvis,  but,  according  to  Tarnier,  the  reverse  is  the  case  when  the 
affected  leg  is  ankvlosed  in  a  position  of  adduction  and  internal  rotation. 

Similar  though  less  marked  changes  take  place  in  the  pelvis  when 
unilateral  luxation  of  the  femur  occurs  in  early  life.     Under  such  circum- 


Fig.  591. 
Figs.  589-591. — Obliquely  Contracted  Pelvis,  Due  to  Unilateral  Luxation  of  Femur. 

stances  the  head  of  the  bone  is  displaced  backward  and  upward  upon  the 
outer  surface  of  the  ilium,  where  a  new  joint  surface  may  occasionally  be 
formed.  The  affected  leg  becomes  considerably  shortened,  and  accordingly 
an  undue  share  of  the  body  weight  is  transmitted  through  the  well  leg, 


674  OBSTETRICS 

which  forces  the  corresponding  side  of  the  pelvis  upward,  inward,  and 
backward,  and  leads  to  an  oblique  contraction,  just  as  in  coxalgia. 

In  unilateral  infantile  paralysis,  and  in  those  cases  in  which  disease  at 
the  knee-  or  ankle-joint,  or  amputation  has  caused  shortening  of  one  leg, 
unless  the  patient  has  had  the  benefit  of  proper  orthopaedic  treatment,  simi- 
lar changes  occur  in  the  pelvis,  though  it  rarely  assumes  the  extreme  degree 
of  obliquity  which  characterizes  the  coxalgic  variety. 

Diagnosis. — A  limping  gait  at  once  suggests  an  oMiquely  contracted 
pelvis,  and  when,  upon  questioning  the  patient,  it  is  found  that  the  condi- 
tion lias  been  present  since  early  childhood,  the  existence  of  pelvic  deform- 
ity upon  the  side  corresponding  to  the  sound  leg  becomes  highly  probable. 

More  accurate  information  can  be  obtained  by  careful  examination  and 
noticing  the  relative  position  of  the  iliac  crests  and  the  presence  or  absence 
of  compensatojxJgftrrosT!^  an  "absolute  diagnosis  can  be  arrived 

at  by  the  employment  oPthe  measurements  suggested  by  Naegele  for  the 
detection  of  the  obliquely  contractecTp>lvis  clue  to  imperiect  development 
of  the  sacral  alas.  An  accurate  conception  concerning  the  degree  of  con- 
traction, however,  can  be  obtained  only  by  careful  exploration  of  the  inte- 
rior of  the  pelvis,  preferably  with  the  patient  under  the  influence  of  an 
anaesthetic,  although  in  many  coxalgic  patients  this  may  be  extremely  diffi- 
cult on  account  of  the  ankylosis  of  one  leg. 

Effect  upon  Labour. — The  effect  of  this  class  of  pelves  upon  labour  varies 
with  the  extent  and  position  of  the  deformity.  If  the  affected  side  is  so 
contracted  as  to  prevent  its  being  occupied  by  a  portion  of  the  present- 
ing part,  we  have  for  all  practical  purposes  a  generally  contracted  pelvis, 
and  engagement,  if  it  can  occur  at  all,  will  take  place  more  readily  when 
the  biparietal  diameter  of  the  head  is  in  relation  with  the  long  oblique 
diameter  of  the  superior  strait.  But  even  after  descent  has  occurred,  all 
obstacles  to  labour  have  by  no  means  been  overcome,  since  in  many  cases 
the  inward  projection  of  the  ischium  may  lead  to  abnormalities  in  rotation. 
■Generally  speaking,  these  pelves  are  not  excessively  contracted,  Prouvost 
reporting  that  40  out  of  the  50  cases  of  labour  complicated  by  them  ended 
spontaneously. 

Treatment. — As  the  pelvic  contraction  is  usually  not  very  pronounced, 
Cesarean  section  is  rarely  indicated,  unless  the  foetus  is  very_lar_ge,_or  the 
history  of  previous  laBorfrs  has  shown  that  the  birth  ofa~living~cnild  is 
out  of  the  question.  When  the  obstacle  to  the  engagement  of  the  head  is 
not  serious,  version  gives  better  results  than  forceps.  This  is  esjogiiiallxtrue 
in  coxalgic  pelves  when  the  ankylosed  leg  and  the  asymmetry  of  the  pubic 
arch  may  make  its  proper  application  practically  impossible. 

Symphyseotomy  is  never  a  justifiable  operation  in  these  cases,  particu- 
larly m  tiiose  due  to  coxalgia,  as  we  nave  no  means  of  determining  in  ad- 
vance whether  the  sacro-iliac  synchondroses  are  synostosed;  and  if  such 
be  the  case  the  operation  cannot  lead  to  an  increase  in  the  capacity  of 
the  pelvic  canal. 

Pelvic  Deformity  Due  to  Bilateral  Lameness. — Occasionally  children  are 
born  with  luxation  of  both  femora,  the  heads  of  the  bones  lying,  as  a 
rule,  upon  the  outer  surfaces  of  the  iliac  bones,  above  and  posterior  to 


PELVIC  ANOMALIES   DUE   TO    BILATERAL    LAMENESS 


675 


their  usual  situation.  In  some  cases  the  acetabula  are  entirely  absent,  but 
more  frequently  they  are  present  in  a  rudimentary  condition,  new  but 
imperfed  substitutes  being  formed  higher  up.  Strange  to  say,  the  con- 
dition dues  nut  usually  seriously  interfere  with  the  individual  in  the  mat- 
ter of  learning  to  walk  at  the  usual  age,  though  the  gait  is  more  or  less 
wabbly. 

The  pelvic  changes  resulting  from  this  condition  have  been  studied 
particularly  by  Kleinwachter,  Schauta,  and  Sassmann,  the  latter  writer 
having  collected  27  cases  from  the  literature.  Owing  to  the  fact  that  the 
upward  and  inward  force 


exerted  by  the  femora  is 
not  applied  in  its  usual 
direction  through  the  ace- 
tabula. the  pelvis  becomes 
unduly  wide,  and  more_o_r 
5S  flattened  antero-pos- 
teriorlv.  The  transverse 
widening  is  particularly 
marked  at  the  inferior 
strait,  while  the  flatten- 
ing, as  a  rule,  is  not  very 
pronounced.  Thus,  the 
conjugata  vera  usually 
measures  between  9  and 
10  centimetres,  and  in 
only  2  of  the  cases  col- 
lected by  Sassmann  was 
it  as  short  as  7  centime- 
tres. Hence,  as  might 
be  expected,  this  pelvis 
rarely  offers  any  serious 
obstacle  to  labour. 

The  patient  presents  a 
characterist  ic  appearance, 
which  is  suggestive  of  that 

Tved  in  spondylolis- 
thesis. Owing  to  the  dis- 
placement of  the  femora 
the  trochanlex%  are  more 
prominent  than  usual,  and  the  width  of  the  buttocks  is  increased.  At  the 
same  time,  owing  to  the  increase  in  the  pelvic  inclination,  there  is  marked 
lordosis,  the  back  of  the  patient  appearing  considerably  shortened  and  pre- 
senting a  marked  saddle-shaped  depression  just  above  the  sacrum. 

According  to  Schauta.  Meyer  described  a  pelvis  obtained  from  an  indi- 
vidual who  had  double  club-foot,  and  found  that  it  was  markedly  funnel- 
shaped.  This  condition  he  attributed  to  the  absence  of  the  usual  spring  at 
the  foot  and  ankle-joints,  and  to  the  fact  that  the  knees  were  held  fixed 
during  walking,  accordingly,  with  each  step  a  distinct  shock  was  imparted 
44 


Fig.  502. — Side  axu  Rear  View  of  Patient  with 
Bilateral  Lcxation  of  Femora. 


676 


OBSTETRICS 


to  the  acetabula,  instead  of  the  more  gentle  force  which  is  exerted  under 
ordinary  circumstances. 

Atypical  Deformities  of  the  Pelvis. — In  rare  instances  the  pelvis  may 
be  more  or  less  deformed  by  the  presence  of  hom/_oii tprowth s  at  various 
points,  and  less  frequently  by  tumour  formations.  Exostoses  axe  most  fre- 
quently observed  upon  the  posterior  surface  of  the  symphysis,  in  front 
of  the  sacro^ilia^-uiints ,  or  upon  the  anterior  surface  of  the  sacrum,  though 
in  occasional  cases  they  may  be  formed  along  the  course  of  the  ilio-pec- 
tineal  line. 

Kilian,  in  1851,  directed  attention  to  the  fact  that  such  structures  may 
form  sharp,  more  or  less  knife-like  projections.  He  designated  the  condi- 
tion as  acantJiopeh/s  or  wJ.vis  ftpinosa^  Such  formations  are  rarely  suffi- 
ciently large  to  offer  any  obstacle  to  labour,  but  owing  to  their  peculiar 
structure  may  do  considerable  injury  to  the  material  soft  parts.  In  fact, 
in  several  of  the  cases  reported,  they  have  cut  through  the  lower  portion 
of  the  uterus. 

In  rare  instances  callus  formation,  resulting  from  inflammatory  pro- 
cesses within  J-ho  pplvis^may  attain  such  proportions  as  to  lead  to  serious 
pelvic  obstruction,  as  in  a  case  reported  by  Ahlfeld. 

Tumour  formations  of  various  kinds  may  spring  from  the  walls  of  the 
true  or  false  pelvis  and  so  obstruct  the  pelvic  cavity  as  to  render  labour 

impossible.  Fibromata,  osteom- 
ata,  enchondromata,  carcinomata, 
and  osteosarcomata  of  the  pelvis 
have  been  described,  and  some- 
times assume  very  considerable 
proportions,  and  occasionally  be- 
come cystic.  Stadfeld  was  able 
to  collect  49  such  cases  in  1879, 
and  Goder  81  cases  in  1895. 
Full  literature  is  to  be  found  in 
their  articles  and  in  the  chap- 
ter of  Schauta  dealing  with  the 
subject. 

The  prognosis  is  very  grave 
when  the  pelvis  is  obstructed  by 
tumours  from  its  walls,  50  per  cent 
of  the  mothers  and  89  per  cent  of 
the  children  having  perished  in 
the  cases  collected  by  Stadfeld, 
while  in  only  11  cases  was  labour 
terminated  by  spontaneous  deliv- 
ery, forceps,  or  version. 

Im  rare  instances,  healed  frac^. 
tures  of  the  pelvis  may  offer  an  insuperable  obstacle  to  the  birth  of  the 
child,  owing  either  to  an  excessive  formation  of  callus  or  to  the  projection 
of  the  broken  ends  of  the  bones  into  the  pelvic  cavity.  This  condition,  how- 
ever, is  very  rare,  as  it  is  stated  that  only  0.8  per  cent  of  all  fractures  involve 


Fig.  593. — Obstruction  of  Pelvic  Canal  by 
Cystic  Enchondroma  (Zweifel). 


ATYPICAL    PELVIC   ANOMALIES 


f.77 


the  pelvis,  and  in  such  cases  the  internal  injuries  are  usually  so  severe  as  to 
lead  to  the  death  of  the  patient,  so  that  only  a  small  proportion  of  such 
women  survive,  and  very  few  of  them  become  pregnant. 

The  effect  upon  labour  depends  upon  the  location  of  the  fracture  and  its 
manner  of  healing.    Fig.  59  I  shows  a  pelvis  described  by  Mars,  and  gives  an 


Fig.  5'J4. — Fractured  Pelvis  (Mars). 

idea  of  the  extent  of  the  changes  which  sometimes  result.  In  a  case  report- 
ed by  Neugebauer,  in  which  there  was  a  transverse  fracture  of  the  second 
sacral  vertebra,  the  vertebral  column  prolapsed  into  the  pelvic  cavity  and 
gave  rise  to  a  deformity  suggestive  of  spondylolisthesis.  For  further  de- 
tails the  reader  is  referred  to  the  articles  of  Schauta  and  Tarnier. 


LITERATURE 

Ahlfeld.     Das  durch  Knochenauswiiehse  verengte  Bee-ken.     Lehrbueh  der  Geburtshiilfe, 

II.  Aufl.,  1898.  336. 
Godek.     Von  dem  Beeken  ausgehende  Tumoren   als  Geburtshinderniss.     D.  I.,  Halle, 

1895. 
Kiliax.     Das  Staehelbecken  (Akanthopelys) ;    Sehilderungen  neuer  Beekenformen,  etc. 

Mannheim,  1854.  59-114. 
Kleixwachter.      Das   Luxationsbeeken,   etc.      Prager    Yierteljahrssehr.   f.    Heilkunde, 

cxviii,  exix. 
Mars.     Schragverengtes  Beeken  infolge   einer   Fractur.     Archiv  f.  Gyn.,  1889,  xxxvi, 

289-300. 
Prouvost.     Etude  sur  les  bassins  vicies  par  boiterie.     These  de  Paris,  1891. 
Sassmaxx.     Das  Beeken  bei  angeborener  doppelseitiger  Htiftgelenksluxation.     Arehiv  1 

Gyn.,  1873.  v,  241-267. 
Schauta.     Mulder's  Handbuch  d.  Geb..  1889.  ii. 

Die  Beekenformen  bei  doppelseitiger  Luxation  der  Schenkelkopfe.  466-472. 
Die  Beckenform  bei  Klumpfuss.  472-473. 
Stadfeld.     Die  Geburt  bei  Geschwiilsten  des  Beckens.     Centralbl.  f.  Gyn.,  18S0,  417-420. 
Tarxier  et  Budix.     Traite  de  Part  des  accouchements.     Paris,  1898,  iii. 
Malformations  du  bassin  dans  la  claudication,  229-278. 
Deformations  atypiques  du  bassin,  338-352. 


CHAPTER    XXXIX 

DYSTOCIA   DUE  TO  ABNORMALITIES  IN  DEVELOPMENT  OR 
PRESENTATION  OF   THE  ECETUS 

Excessive  Development. — -As  was  stated  in  Chapter  V,  the  child  at  birth 
rarely  exceeds  12  pounds  (5,600  grammes)  in  weight,  though  authentic  ac- 
counts of  much  larger  infants  are  to  be  found  in  the  literature. 

Provided  the  pelvis  is  not  contracted,  it  is  very  exceptional  for  a  nor- 
mally formed  child,  weighing  less  than  10^  pounds  (5,000  grammes),  to 
give  rise  to  dystocia  by  its  mere  size.'  In  overdeveloped  children  the  diffi- 
culty is  generally  due  to  the  fact  that  the  head  tends  to  become  not  only 
larger  but  harder,  and  consequently  less  malleable  with  increasing  weight; 
although  it  sometimes  happens  that  after  the  head  has  passed  through  the 
pelvic  canal  without  difficulty  the  dystocia  may  be  due  to  the  arrest  of  the 
unusually  large  shoulders  either  at  the  pelvic  brim  or  outlet.  On  the  other 
hand,  when  the  pelvis  is  abnormal,  great  difficulty  may  be  experienced  in 
delivering  even  moderately  sized  children. 

Excessive  development  of  the  foetus  can  usually  be  traced  to  one  of 
four  causes:  prolongation  of  pregnancy,  large  size  of  one  or  both  parents, 
advancing  age,  or  multiparity  of  the  mother. 

Cases  in  which  three  hundred  days  or  more  elapse  between  the  last 
menstrual  period  and  the  onset  of  labour  are  not  uncommon,  but  in  the 
majority  of  these  the  prolongation  of  pregnancy  is  only  apparent,  and 
merely  means  that  fertilization  of  the  ovum  took  place  just  before  the  first 
period  missed,  instead  of  shortly  after  the  last  menstrual  flow.  On  the  other 
hand,  actual  prolongation  is  occasionally  observed,  and  is  liable  to  exert  a 
serious  influence  upon  the  course  of  labour,  inasmuch  as  the  child  increases 
steadily  in  size  for  every  additional  day  it  remains  in  the  uterus.  Accord- 
ingly, whenever  it  seems  probable  that  gestation  has  gone  on  beyond  the 
normal  term,  the  patient  should  be  carefully  watched  and  examined  at 
frequent  intervals,  so  that  labour  may  be  induced  as  soon  as  there  is  any 
sign  of  disproportion  between  the  size  of  the  head  and  the  pelvis. 

More  frequently  the  excessive  size  of  the  child  is  due  to  the  fact  that 
one  or  both  of  its  parents  are  unusually  large;  moreover,  it  is  a  matter  of 
common  observation  that  the  foetal  head  in  many  instances  resembles  that 
of  its  father,  large-headed  men  usually  producing  children  with  similar 
characteristics.  The  age  of.  the  mother  has  likewise  an  important  influ- 
ence upon  the  foetal  development.  Thus,  the  children  of  elderly  primiparae 
678 


DYSTOCIA   DUE   TO   EXCESSIVE    DEVELOPMENT    OF   FCETUS       679 

often  exceed  the  ordinary  average,  and  in  multipara'  I  lie  children  arc  oil  en 
Larger  with  each  successive  pregnancy,  provided  they  do  not  follow  in  too 
rapid  succession. 

As  a  rule,  large-headed  children  have  hard  and  well  ossified  heads. 
This  is  more  particularly  true  for  males,  in  whom  the  biparietal  diameter 
is  usually  somewhat  greater  than  in  female  children  of  the  same  size.  In 
such  cases  the  inability  of  the  head  to  become  moulded  not  only  interferes 
with  its  engagement,  but  predisposes  to  certain  injuries,  such  as  spoon- 
shaped  depressions  of  the  skull,  when  artificial  delivery  becomes  necessary. 

Although  in  the  case  of  a  normal  pelvis  a  moderate  increase  in  the  size  of 
the  child  is  usually  without  any  practical  significance,  when  any  degree  of 
contraction  exists  such  a  condition  may  make  all  the  difference  between  an 
easy  and  a  difficult  labour.  At  the  same  time,  it  must  be  remembered  that 
in  multiparous  women  the  dystocia  is  often  due  in  great  part  to  the  loss  of 
tone  of  the  uterine  musculature  incident  to  repeated  childbearing. 

Inasmuch  as  we  possess  no  perfectly  satisfactory  means  of  determining 
the  size  of  the  child,  and  particularly  of  its  head,  the  diagnosis  of  excessive 
development  is,  as  a  rule,  not  established  until  after  fruitless  attempts  at 
delivery  have  been  made.  Nevertheless,  a  careful  routine  examination  will 
often  enable  the  obstetrician  to  arrive  at  fairly  accurate  conclusions  and 
prepare  him  to  meet  this  complication. 

Generally  speaking,  if  the  pelvis  is  normal,  the  failure  of  engagement 
in  the  last  weeks  of  pregnancy  in  a  primipara,  or  the  existence  of  a  face, 
brow,  or  transverse  presentation  should  suggest  the  probability  of  an  ex- 
cessively large  head.  Accurate  bimanual  palpation  frequently  confirms 
such  a  suspicion,  especially  when  Muller's  method  of  impression  fails  to 
cause  the  head  to  enter  the  pelvis. 

Treatment. — Owing  to  the  difficulty  of  clinching  the  diagnosis,  the 
treatment  is  usually  very  unsatisfactory.  If  the  patient  has  gone  several 
weeks  beyond  term,  and  examination  shows  that  the  head  is  probably  exces- 
sively large,  there  should  be  no  hesitancy  in  the  immediate  induction  of 
labour,  the  operation  being  particularly  indicated  in  multiparous  women 
whose  history  shows  that  excessive  foetal  development  was  the  cause  of  the 
previous  difficult  labours.  On  the  other  hand,  if  the  pregnancy  is  not  pro- 
longed, the  condition  is  rarely  suspected  at  the  outset  of  labour,  and  the 
diagnosis  is  made  only  after  Nature  has  shown  that  she  is  unable  to  effect 
delivery.  In  such  cases  it  is  often  very  difficult  to  determine  upon  the 
best  method  of  dealing  with  the  complication.  If  careful  examination 
shows  that  the  head  is  excessively  large  and  well  ossified,  the  advisability 
of  Cesarean  section  may  be  considered  if  the  patient  is  intensely  desirovis 
of  offspring;  though  it  should  be  remembered  that,  owing  to  the  manipula- 
tions which  have  usually  preceded  it,  the  prognosis  is  not  so  favourable  as 
in  frank  cases,  and  accordingly  the  operation  has  only  a  limited  field  of  use- 
fulness. In  most  cases,  however,  when  delivery  appears  imperative,  better 
results  are  obtained  by  version  than  by  the  employment  of  forceps  upon  the 
freely  movable  head. 

When  the  obstacle  to  delivery  is  due  to  excessive  size  of  the  shoulders 
rather  than  of  the  head,  labour  can  often  readily  be  terminated  after  dimin- 


680  OBSTETRICS 

ishing  the  size  of  the  shoulder  girdle  by  cutting  through  the  clavicles  with 
a  pair  of  heavy  scissors — cleidotomy. 

Malformations  of  the  Foetus. — Double  Monsters. — For  practical  purposes 
3  groups  of  double  monsters  may  be  distinguished:  (1)  Incomplete  double 
formations  at  the  upper  or  lower  half  of  the  body  (diprosopus,  dipagus); 
(2)  twins  which  are  united  together  at  the  upper  or  lower  end  of  the  body 
(craniopagus,  isehiopagus,  or  pygopagus);  (3)  double  monsters  which  are 
united  by  the  trunk  (thoracopagus  and  dicephalus). 

The  diagnosis  of  any  one  of  these  conditions  is  not  made  until  the  serious 
difficulty  experienced  in  attempting  delivery  has  led  to  careful  explora- 
tion under  anaesthesia  with  the  entire  hand,  although  in  many  cases  the 
existence  of  a  multiple  pregnancy  may  have  been  suspected.  As  such  mon- 
strosities frequently  present  minor  deformities  as  well,  the  detection  of  a 
clubfoot,  hare-lip,  etc.,  should  always  direct  one's  attention  to  the  possible 
existence  of  some  still  more  serious  abnormality. 

Fortunately  the  delivery  of  many  monstrosities  is  much  more  readily 
accomplished  than  would  appear  possible  at  first  sight.  In  the  first  place, 
such  pregnancies  rarely  go  on  to  full  term,  so  that  the  monstrosity  rarely 
exceeds  a  normal  child  in  size.  In  the  second  place,  the  connection  be- 
tween the  two  halves  is  often  of  such  a  character  as  to  permit  of  sufficient 
motility  between  the  component  parts  as  to  make  their  successive  delivery 
possible. 

On  the  other  hand,  in  the  first  group  the  large  size  of  the  doubled  portion 
of  the  monster  may  lead  to  serious  mechanical  obstacles  at  the  time  of  deliv- 
ery. The  fused  head  in  a  diprosopus  is,  as  a  rule,  much  more  readily  deliv- 
ered when  it  forms  the  after-coming  part  than  when  it  presents  primarily. 
In  the  second  group,  a  craniopagus  presenting  by  the  head  usually  causes  only 
a  moderate  amount  of  difficulty;  whereas,  on  the  other  hand,  iscliiopagi  and 
pygopagi,  as  a  rule,  call  for  complicated  and  difficult  manoeuvres  before 
delivery  can  be  effected. 

In  the  third  group,  the  delivery  of  diceplialic  monsters  is  facilitated 
when  they  present  by  the  breech,  as  in  many  cases  first  one  and  then  the 
other  head  can  be  extracted.  On  the  other  hand,  in  cephalic  presentations 
the  two  heads  may  mutually  interfere  with  one  another  and  thus  prevent 
engagement  until  one  has  been  diminished  in  size  by  craniotomy.  When 
engagement  of  one  head  occurs,  delivery  can  be  partially  effected  by  forceps, 
but  as  a  rule  the  head  cannot  be  delivered  beyond  the  pubic  arch,  for  the 
reason  that  further  descent  is  prevented  by  the  arrest  of  the  second  head 
at  the  superior  strait.  Under  such  circumstances  it  is  advisable  to  amputate 
the  first  head,  after  which  delivery  of  the  rest  of  the  monster  is,  as  a  rule, 
best  accomplished  by  version. 

Thoracopagi  usually  offer  a  less  serious  obstacle  to  delivery,  for  the 
reason  that  they  are  frequently  so  loosely  connected  with  one  another  that 
considerable  motility  is  possible.  Indeed,  it  is  not  unusual  for  the  2  children 
to  present  in  a  different  manner.  When  possible,  it  is  advisable  to  bring 
down  all  four  feet  at  the  same  time,  and  to  effect  extraction  in  such  a  way 
that  the  posterior  head  is  first  delivered.  In  cephalic  presentations,  the 
head  and  body  of  the  first  child  are  expelled,  and  the  second  child  is  then 


DYSTOCIA   DUE   TO   DEFORMITIES   OF    F(ETUS 


081 


born  very  much  as  in  an  ordinary  twin  pregnancy.  If,  however,  the 
latter  presents  transversely,  its  delivery  can  be  effected  only  by  version  and 
exl  raci  ion. 

Deformities  of  Foetus. —  In  this  place  attention  will  be  directed  only 
tn  those  abnormalities  in  Ecetal  development  which  may  give  rise  to  diffi- 
cult  labour.  An  acardiacus  is  a  monster  which  is  sometimes  developed  in 
single-ovum  twin  pregnancies  as  the  result  of  inequalities  in  the  commu- 
nicating placental  circulation.  One  twin  is  well  developed  and  normal, 
while  the  other  is  imperfectly  formed  and  lacks  a  heart.  The  way  in  which 
this  is  brought  about  was  considered  on  page  329. 

The  most  common  variety  of  acardiac  monster  is  the  acephalicus  or 
headless  fcetus.  Less  common  is  the  amorphous  monster,  which  possesses 
neither  a  head  nor  extremities,  but  is  round  in  shape  and  presents  upon 
its  surface  a  number  of  small  nodules,  which  represent  the  rudimentary 
extremities.  The  umbilical  cord  may  be  attached  to  any  portion  of  its 
surface.  The  interior  of  the  monstrosity  contains  a  rudimentary  intestinal 
tract,  cystic  cavities,  vertebra?,  etc.,  but  no  trace  of  a  heart.  The  rarest 
variety  of  acardiacus  is  the  acormus  or  trunkless  monster,  which  consists  of 
an  imperfectly  developed  head  and  a  rudi- 
mentary body,  the  umbilical  cord  being 
attached  to  the  cervical  region. 

As  a  rule  such  monsters  do  not  attain 
any  notable  size,  although  exceptionally, 
as  the  result  of  obstruction  in  the  umbilical 
vein,  they  may  become  cedematous  and 
give  rise  to  dystocia. 

The  anenceplialus  or  hemiceplialus  is  a 
monster  possessing  a  trunk,  but  only  an 
imperfectly  developed  head,  from  which 
a  large  part  of  the  brain  and  skull  is  lack- 
ing. Ordinarily,  such  beings  are  of  moder- 
ate size,  but  occasionally  the  shoulders  may 
he  so  excessively  developed  as  to  give  rise 
to  serious  dystocia. 

Owing  to  the  absence  of  the  cranial  vault,  the  face  is  very  prominent 
and  somewhat  extended,  the  eyes  often  protrude  markedly  from  their 
sockets,  and  the  tongue  hangs  from  the  mouth.  The  brain  is  in  a  rudi- 
mentary condition,  and  the  base  of  the  skull  is  accessible  to  the  examining 
finger,  so  that  the  sella  turcica  can  be  distinguished.  Owing  to  the  ex- 
posed condition  of  the  base  of  the  brain  and  the  upper  part  of  the  medulla, 
there  is  frequently  a  marked  increase  in  the  amount  of  amniotic  fluid,  its 
production  being  analogous  to  that  noted  in  the  picure  experiments  of  the 
physiologists. 

In  view  of  the  abnormal  shape  of  the  head,  face  presentations  are  fre- 
quently observed,  while  those  of  the  vertex  are  less  common  than  with 
-a  normal  fcetus.  Transverse  and  foot  presentations  are  likewise  not 
unusual. 

When  the  monstrosity  presents  by  the  face  or  head,  a  correct  diagnosis 


Fig.  595. — Anenoepdalus  (Schroeder). 


682 


OBSTETRICS 


is  frequently  made  by  vaginal  touch,  the  characteristic  bulging  of  the 
eyes  being  noted  in  the  former,  and  the  absence  of  the  cranial  vault  and  the 
presence  of  the  sella  turcica  in  the  latter  presentation. 

Delivery,  as  a  rule,  occurs  much  more  readily  when  the  monster  pre- 
sents by  the  breech,  for  the  reason  that  the  imperfectly  developed  head 
is  not  an  efficient  dilating  agent,  though  in  many  cases  rapid  and  spon- 
taneous delivery  is  observed.  Even  when  the  enlarged  shoulders  give  rise 
to  dystocia,  delivery  can  usually  be  accomplished  by  means  of  version  with- 
out any  great  difficulty. 

Hydrocephalus. — -In  this  not  very  rare  condition,  the  cerebral  ventricles 
are  distended  by  an  excessive  amount  of  cerebro-spinal  fluid  (Fig.  596). 
As  a  result  the  skull  becomes  much  increased  in  size,  not  infrequently 

attaining  several  times  its  normal  dimen- 
sions, while  the  brain  substance  forms  a 
layer  only  a  few  millimetres  thick  beneath 
it.  At  the  same  time  the  cranial  bones  are 
imperfectly  developed,  the  sutures  and 
fontanelles  being  much  wider  than  usual. 


Fig.  596. — Dystocia  Due  to  Hydrocephalus  (Bumm). 


If  the  enlarged  head  is  not  tensely  filled  with  fluid,  under  the  influence 
of  the  uterine  contractions,  it  may  undergo  such  changes  in  shape  that  its 
spontaneous  expulsion  becomes  possible.  This,  however,  is  so  rare  a  pos- 
sibility that  it  should  not  be  reckoned  with  in  determining  the  treatment 
to  be  pursued  in  a  given  case.  Still  less  frequently,  owing  to  the  pressure 
to  which  the  head  is  subjected  at  the  time  of  labour,  the  tissues  forming  a 
fontanelle  or  suture  may  give  way,  so  that  the  cerebro-spinal  fluid  can  es- 
cape, after  which  the  head  collapses  and  spontaneous  delivery  becomes  pos- 
sible. In  the  vast  majority  of  cases,  however,  the  condition  gives  rise  to 
serious  dystocia,  which  if  not  promptly  relieved  will  lead  to  rupture  of  the 
uterus  and  the  death  of  the  patient  from  intra-abdominal  hgemorrhage. 

In  hydrocephalic  children,  although  cephalic  presentations  predomi- 
nate, owing  to  the  lack  of  accommodation  between  the  head  and  the  pelvic 
canal  the  breech  is  often  substituted. 


DYSTOCIA    DUE   TO    HYDROCEPHALUS  (is;; 

Diagnosis. — As  a  rule  the  condition  is  no1  recognised  until  several  hours 
of  fruitless  second-stage  pains  have  demonstrated  the  existence  of  an  ob- 
stacle to  delivery.  On  the  oilier  hand,  careful  examination  should  ordi- 
narily lead  t<>  a  correct  diagnosis  in  the  last  weeks  of  pregnancy  or  soon 
after  the  onset  of  labour.  In  many  cases  the  deformity  can  be  detected 
by  external  palpation,  the  immensely  large  and  movable  head  being  iso- 
lated a  hove  the  superior  strait  or  in  the  fundus  of  the  uterus.  Furthermore, 
the  examiner  should  always  lie  on  the  lookout  for  the  presence  of  fluctua- 
tion, while  a  peculiar  crackling  sensation  can  be  elicited  by  pressure  upon 
the  skull.  1  have  made  a  positive  diagnosis  in  this  manner  upon  several 
occasions  without  an  internal  examination. 

As  soon  as  the  cervix  is  dilated,  vaginal  examination  will  reveal  a  large 
head  with  widely  gaping  sutures,  through  which  fluctuation  can  be  obtained 
by  appropriate  manoeuvres.  Of  course  this  does  not  hold  good  in  those 
cases  in  which  the  child  presents  by  the  breech,  but  here  abdominal  pal- 
pation will  reveal  the  presence  of  the  large  fluctuant  head  in  the  fundus  of 
the  uterus,  or  just  above  the  superior  strait,  in  case  attempts  at  extraction 
have  been  made. 

Prognosis. — For  the  child  the  outlook  is  uniformly  bad,  for  even  if 
born  alive  it  usually  succumbs  within  a  few  days,  and  in  the  rare  cases  in 
which  it  survives,  grows  up  a  hopeless  idiot.  The  maternal  prognosis  de- 
pends largely  upon  the  obstetrician.  If  left  to  Nature,  the  usual  termi- 
nation of  labour  complicated  by  hydrocephalus  is  rupture  of  the  uterus; 
whereas,  if  the  condition  be  detected  and  proper  treatment  instituted,  the 
results  are  almost  universally  favourable. 

Treatment. — As  soon  as  the  cervix  has  become  completely  dilated,  the 
head  should  be  perforated,  in  order  that  the  cerebro-spinal  fluid  can  escape 
and  the  skull  collapse,  after  which  delivery  can  be  effected  by  the  unaided 
efforts  of  Nature,  or  may  be  accelerated  b}>-  the  employment  of  the  cranio- 
clast.  On  account  of  the  nature  of  the  disease  and  its  effect  upon  the  child, 
the  operation  may  be  undertaken  without  hesitancy, .  even  by  those  who 
ordinarily  do  not  consider  craniotomy  a  justifiable  procedure. 

In  evacuating  the  hydrocephalic  head  it  should  be  borne  in  mind  that, 
owing  to  the  extreme  thinness  of  the  brain,  mere  perforation  is  not  always 
synonymous  with  foetal  death.  For  this  reason  the  perforator  should  be 
carried  to  the  base  of  the  skull  and  vigorously  manipulated  in  order  to 
destroy  the  medulla,  as  nothing  could  be  more  horrible  than  the  extraction 
of  a  living  child  after  such  an  operation. 

Enlargement  of  the  Abdomen  of  the  Foetus. — Enlargement  of  the  abdo- 
men sufficient  to  cause  grave  dystocia  is  usually  the  result  of  ascites,  a 
very  much  distended  bladder,  or  of  tumours  of  the  kidneys  or  liver. 

Whenever  the  abdominal  distention  is  marked,  spontaneous  labour  is 
out  of  the  question;  but,  unfortunately  the  condition  usually  escapes  detec- 
tion until  fruitless  attempts  at  delivery  have  demonstrated  the  existence 
of  some  obstruction  and  have  led  the  obstetrician  to  introduce  his  entire 
hand  into  the  uterus  in  the  hope  of  discovering  its  nature. 

Occasionally  a  foetus  affected  with  general  dropsy  may  attain  such  im- 
mense proportions  that  spontaneous  delivery  is  impossible.     A  number  of 


■684 


OBSTETRICS 


J 


s ,  Mm' 


such  cases  are  recorded  in  Ballantyne's  valuable  monograph.  In  very  rare 
instances  the  ascites  associated  with  foetal  peritonitis  may  have  a  similar 
result,  and  exceptionally  a  foetus  suffering  from  chondro  dystrophia  or  foetal 
rhachitis  may  become  so  cedematous  as  to  give  rise  to  dystocia. 

As  the  result  of  the  dilatation  of  the  superficial  lymphatics  associated 
with  oedema  of  the  subcutaneous  tissues,  the  foetus  may  assume  immense 
proportions  and  take  on  a  bizarre  shape.  This  condition,  which  is  desig- 
nated as  elephantiasis  congenita  cystica,  has  been  studied  in  detail  by  Bal- 
lantyne,  and  is  a  very  rare  cause  of  difficult  labour  (Fig.  597). 

Defective  development  of 
the  lower  portion  of  the  uri- 
nary tract  may  lead  to  the  re- 
tention of  urine  accompanied 
by  distention  of  the  abdomen 
sufficient  to  render  normal  de- 
livery impossible  (Fig.  598). 
Examples  of  this  condition 
have  been  reported  by  Wal- 
g.  ther,    Schwyzer,    and    others, 

-  W      who  also  give  details  as  to  its 
• —  .Jk- .  aetiology. 

'_■■•-      tj'\  A    much    more    frequent 

?*€2 \   \  cause    of    abdominal    enlarge- 

ment is  the  presence  of  con- 
f^M  V  : ■'      **  genital    cystic    kidneys.       The 

j^jf"W.-       *       t\  ■  growth,  which  is  histological- 

ly an  adenocystoma,  may  in- 
J  ^f '  "   "'  volve  one  or  both  organs,  and 

"    i  give   rise   to   tumours   of   im- 

m  mense  size.     The  condition  is 

Ifc  y  frequently  associated  with  dila- 

tation of  the  ureters,  and  with 
dropsical  effusions  into  the  va- 
rious body  cavities.  Fig.  599 
gives  an  idea  of  the  extent  of 
the  abdominal  enlargement  in 
a  case  which  I  delivered. 

Mirabeau,  Theilhaber,  Ha- 
nau,  Brouha,  and  many  others  have  recently  studied  the  condition  in  detail 
from  an  anatomical  point  of  view,  and  have  likewise  considered  its  practical 
obstetrical  bearings. 

In  rare  cases  the  abdominal  enlargement  may  be  due  to  tumours  of  the 
liver,  Porak  and  Couvelaire  having  reported  a  case  of  congenital  cystic 
liver  associated  with  a  similar  condition  of  the  kidneys.  Moreover,  large 
tumours,  arising  from  any  of  the  abdominal  organs,  may  give  rise  to  dystocia. 
Thus,  Bogers  has  described  an  immense  fibro-cystic  testicle,  and  Phaenome- 
now  an  aortic  aneurysm  so  large  as  to  interfere  with  delivery.  In  rare 
instances  foetal  inclusions,  such  as  the  so-called  foetus  in  foetu,  may  be 


&.*..■    ■ 


Fig.  597. — Elephantiasis  Congenita  Cystica 
(■Ballantyne). 


DYSTOCIA    DUE  TO    DISEASES  OF   FOETUS 


685 


7 


Fig.  oi 


— FcETlS    WITH    IMMENSELY   DISTENDED    B LADDER 

(Hecker). 


responsible.     Occasionally  the  invasion  by  Bacillus  acrogenes  capsulatus 

may  be  followed  by  such  an  extensive  production  of 

gas  thai   the  Ecetus  becomes  more 

than  double  the  normal  size  when  ;&£& 

spontaneous  delivery  is  impossible.         1$ 

In  all  of  these  conditions,  if  the  jB 
dystocia  is  marked,  deliv- 
ery ran  In'  accomplished 
only  after  opening  the 
body  of  tin1  Eoetus  and 
allowing  the  fluid  to  es- 
cape, or  removing  a  por- 
tion, at  least,  of  the 
offending  tumour  forma- 
tion. The  latter  opera- 
tion is  not  always  easy, 
for,  owing  to  the  con- 
strained position  of  the 
hand  in  utero  and  the 
dense  consistency  of  the 
growth  in  many  cases, 
great  difficulty  is  experi- 
enced in  completing  it. 

Tumours  of  the  Body 
of  the  Fains. — In  rare 
instances,  abnormal 
growths  arising  from  va- 
rious portions  of  the 
"body  of  the  foetus  may 
seriously  interfere  with 
•delivery.  Cases  are  on 
record  in  which  lipom- 
ata,  carcinomata,  an- 
giomata,  and  various 
other  tumours  have 
given  rise  to  such  an  en- 
largement that  sponta- 
neous delivery  became 
out  of  the  question.  Ex- 
ceptionally, dermoid 
cysts  and  teratomatous 
tumours  about  the  peri- 
nseum  and  sacrum  may 
offer  a  serious  obstacle. 
Fig.  256  represents  a  foe- 
tus in  which  an  adenoma 
of  the  thyroid  gland  ne- 
cessitated   a    destructive  Fig.  599.— F<etcs  with  Congenita!  Cystic  Kidneys. 


686  OBSTETRICS 

operation.  In  rare  instances  parasitic  foetal  tumours,  a  large  umbilical  her- 
nia, a  spina  bifida,  and  other  growths,  give  rise  to  difficult  labour. 

Dystocia  Due  to  Abnormal  Presentations  of  the  Foetus — Transverse 
Presentations. — In  this  condition  the  long  axis  of  the  foetus  crosses  that 
of  the  mother  at  about  a  right  angle.  When  it  forms  an  acute  angle  we 
speak  of  an  oblique  presentation.  The  latter,  however,  is  usually  only 
transitory,  becoming  converted  into  a  longitudinal  presentation  when  labour 
supervenes. 

In  transverse  presentations  the  shoulder  usually  occupies  the  superior 
strait,  the  head  lying  in  one  and  the  breech  in  the  other  iliac  fossa  (Figs. 
600  and  601).  Accordingly,  such  a  condition  is  commonly  spoken  of  as  a 
shoulder,  and  less  frequently  as  a  lateral  plane  presentation.  As  the  acromion 
process  is  one  of  the  most  characteristic  features  of  the  shoulder,  these  are 
usually  designated  as  acromio-iliac  presentations,  the  position  being  right 
or  left  according  to  the  side  of  the  mother  towards  which  the  shoulder  is 


Fig.  600. — Diagram  showing  Left  Acromio-  Fig.  601. — Diagram  showing  Eight  Acromio- 

iliac    DORSO-POSTERIOR    PRESENTATION.  ILIAC    DORSO- ANTERIOR   PRESENTATION. 

directed.  Moreover,  in  either  position,  the  back  may  be  directed  either  ante- 
riorly or  posteriorly,  and  accordingly  it  is  customary  to  distinguish  between 
the  dor  so-anterior  and  dor  so-posterior  varieties.  The  recognition  of  the 
position  of  the  back  is  of  very  considerable  importance  in  connection  with 
the  proper  performance  of  version — the  treatment  par  excellence  in  this, 
condition. 

According  to  Schroeder,  the  shoulder  is  directed  towards  the  left  side 
of  the  mother  2.6  times  more  frequently  than  towards  the  right,  while 
the  back  looks  anteriorly  2.5  times  more  frequently  than  posteriorly. 

/Etiology. — The  existence  of  a  transverse  presentation  in  a  primiparous 
woman  is.  prima  facie  evidence  of  a  lack  of  accommodation,  usually  the 
result  of  disproportion  between  the  size  of  the  head  and  the  pelvis.  In 
rare  instances  it  may  be  clue  to  hydramnios.  In  multiparas,  on  the  other 
hand,  the  most  frequent  serological  factor  is  an  abnormal  relaxation  of  the 
abdominal  and  uterine  walls,  the  result  of  repeated  childbearing,  which 
may  be  still  further  complicated  by  any  of  the  causes  already  enumerated. 
Accordingly,  transverse  presentations  are  much  more  frequently  observed  in 
women  who  have  borne  a  number  of  children,  and  in  them,  as  a  rule,  the 


PLATE  XV. 


PALPATION  IN  LEFT  ACKOMIO-ILIAC,  DOESO-ANTEKIOK  PEESENTATION. 


DYSTOCIA' DUE  TO  TRANSVERSE   PRESENTATION   OF    F03TUS    687 

condition  is  no1  so  serious  as  in  primiparaB,  for  the  reason  thai  in  the  former 
spontaneous  reposition  frequently  ensues  after  the  onsel  of  labour  pains, 
the  child  assuming  a  longitudinal  presentation,  whereas  such  an  occurrence 
is  exceptional  in  the  latter. 

This  spontaneous  conversion  into  a  longitudinal  presentation  is  ren- 
dered more  difficull  by  premature  nipture  of  the  membranes,  as  well  as 
by  any  condition  which  interferes  with  the  descent  or  engagement  of  the 
head;  for  example,  a  contracted  pelvis,  placenta  pnevia,  a  pelvic  tumour, 
or  twin  pregnancy.  In  rare  instances  longitudinal  may  become  converted 
into  secondary  transverse  presentations  at  the  time  of  labour,  although 
such  an  occurrence  is  exceptional,  and  is  always  indicative  of  disproportion 
between  the  size  of  the  child  and  the  pelvis. 

Diagnosis. — The  diagnosis  of  a  transverse  presentation  is  usually  readily 
made,  inspection  alone  frequently  causing  one  to  suspect  its  existence. 
The  abdomen  is  seen  to  be  unusually  wide  from  side  to  side,  while  the 
fundus  of  the  uterus  frequently  does  not  extend  above  the  umbilicus. 

On  palpation  the  first  manoeuvre  reveals  the  absence  of  the  head  or  the 
breech  from  the  fundus.  On  the  second  manoeuvre  a  ballottable  head  will 
be  found  in  one  and  the  breech  in  the  other  iliac  fossa,  while  the  third 
and  fourth  manoeuvres  are  negative,  unless  labour  has  been  in  progress 
for  some  time  and  the  shoulder  has  become  impacted  in  the  pelvis.  At 
the  same  time  the  position  of  the  back  is  readily  diagnosed.  When  it  is 
situated  anteriorly,  a  hard  resistant  plane  will  be  felt  extending  across  the 
front  of  the  abdomen;  when  it  lies  posteriorly,  irregular  nodulations,  rep- 
resenting the  small  parts,  will  be  felt  in  the  same  location  (Plate  XV). 

On  vaginal  touch  in  the  early  stages  of  labour,  the  side  of  the  thorax, 
readily  recognisable  by  the  "  gridiron  "  sensation  afforded  by  the  ribs,  can 
be  made  out  at  the  superior  strait.  "When  dilatation  is  further  advanced, 
the  scapula  can  be  distinguished  on  one  and  the  clavicle  on  the  other  side 
of  the  thorax,  while  the  position  of  the  axilla  will  indicate  towards  which 
side  the  shoulder  is  directed.  Later  in  labour  the  shoulder  becomes  wedged 
down  in  the  pelvic  canal,  and  a  hand  and  arm  not  infrequently  prolapse 
into  the  vagina;  whether  it  is  the  right  or  left  can  be  readily  determined 
by  ascertaining  to  which  one  of  the  obstetrician's  it  corresponds,  just  as 
in  shaking  hands. 

Course  of  Labour. — With  very  rare  exceptions,  spontaneous  labour  is 
impossible  in  persistent  transverse  presentations,  since  expulsion  cannot 
be  effected  unless  both  the  head  and  trunk  of  the  child  enter  the  pelvis  at 
the  same  time,  a  manifestly  impossible  event  when  both  are  of  normal 
proportions.  Accordingly,  both  the  foetus  and  mother  must  inevitably 
perish  if  appropriate  measures  are  not  instituted. 

After  rupture  of  the  membranes,  if  the  patient  is  left  to  herself  an  arm 
usually  prolapses  and  the  shoulder  becomes  forced  down  into  the  pelvic 
cavity,  but  can  descend  for  only  a  certain  distance,  being  arrested  by  the 
head  and  trunk  at  the  superior  strait.  The  uterus  then  contracts  vigorously 
in  the  attempt  to  overcome  the  obstacle,  but  in  vain.  After  a  certain  time 
the  contraction  ring  rises  higher  and  higher,  the  lower  uterine  segment 
becomes  more  and  more  stretched  and  eventually  gives  way,  when  a  part 


OBSTETRICS 


or  the  whole  of  the  product  of  conception  escapes  into  the  abdominal  cavity. 
Under  such  circumstances  the  patient  usually  succumbs  within  a  short 
time  to  intraperitoneal  haemorrhage,  while  in  other  instances  death  occurs 
after  a  longer  or  shorter  period  from  infection. 

Possibly  once  in  many  thousand  cases  the  uterus  ceases  to  contract  be- 
fore rupture  occurs,  the  child  being  retained  within  the  uterus,  may  eventu- 
ally become  converted  into  a  lithopaedion,  to  be  finally  cast  off  by  suppura- 
tive processes.  So  far  as  I  know,  such  a  condition  has  not  been  described 
in  human  beings,  though  it  is  well  known  to  the  veterinarians.  Neverthe- 
less, the  experience  of  Resnikow,  who  removed  the  suppurating  fragments 
of  a  foetus  from  the  uterus  four  years  after  the  expected  date  of  confinement, 
is  very  suggestive. 

In  transverse  presentations,  now  and  again,  spontaneous  delivery  en- 
sues. Bartholin,  in  the  seventeenth  century,  pointed  out  that  a  child  which 
has  lain  transversely  during  the  later  months  of  pregnancy  may  spontane- 
ously assume  a  longitudinal  presentation  at  the  time  of  labour.  This  so- 
called  spontaneous  version  is  a  not  infrequent  occurrence.  Its  mode  of  pro- 
duction has  already  been  referred  to. 

A  century  later,  Eoederer  pointed  out  that  in  very  rare  instances,  if 
the  child  was  small  and  the  pelvis  large,  delivery  might  occasionally  be 
accomplished  in  spite  of  the  persistence  of  the  abnormal  presentation. 
This  process  he  designated  spontaneous  evolution.  The  monograph  of  Payer 
is  replete  with  historical  allusions  to  the  subject. 

Spontaneous  version  occurs  only  in  the  early  stages  of  labour,  and  its 
occurrence  should  not  be  looked  for  after  the  rupture  of  the  membranes. 


Fig.  602. — Frozen  Section  through  Woman  Dting  in  Labour  with  a  Neglected  Transverse 

Presentation  (Chiara) 

Spontaneous  evolution,  on  the  other  hand,  is  possible  only  late  in  labour 
after  the  membranes  have  ruptured  and  the  shoulder  has  become  wedged 
down  into  the  pelvic  cavity.    This,  however,  is  met  with  so  rarely,  demands 


DYSTOCIA   DUE  TO  TRANSVERSE  PRESENTATION   OF   PCETUS     689 

such  peculiar  conditions,  and  is  attended  by  such  risks  to  the  mother,  thai 
its  occurrence  should  never  be  counted  upon  in  actual  practice. 

When,  however,  the  pelvis  is  normal  and  the  child  undersized,  and  par- 
ticularly if  it  is  macerated,  spontaneous  evolution  may  be  effected  in  one 

of  two  ways  provided  the  pains  are  sulliciently  strong.  Thus,  the  impacted 
shoulder  after  being  dri\  en  deeper  and  deeper  into  the  pelvis  may  eventually 
rotate  to  the  front  and  emerge  from  the  vulva,  its  expulsion  being  followed 
by  the  rest  of  the  thorax  and  then  by  the  feet,  while  the  head  still  remains 
above  the  superior  strait  (Fig.  603).    Less  frequently,  particularly  if  the 


Fig.  603. — Diagram  illustrating  Mechanism  of  Spontaneous  Evolution  (Jungmann). 

child  is  macerated,  the  shoulder  may  be  forced  down  through  the  pelvis, 
while  the  body  is  so  bent  upon  itself  that  the  head  and  thorax  come  into 
close  apposition  and  eventually  enter  the  pelvis  together.  The  birth  of  the 
shoulder  is  followed  by  that  of  the  head  and  thorax,  which  emerge  simulta- 
neously from  the  vulva,  and  are  followed  by  the  breech  and  lower  extremi- 
ties.   This  mechanism  is  described  as  partus  conduplicato  corpore  (Fig.  60-i). 

In  very  rare  instances  spontaneous  evolution  may  occur  even  when  the 
child  has  attained  considerable  proportions.  Thus,  Payer  has  reported  the 
case  of  a  child  weighing  2,650  grammes  and  measuring  50  centimetres  in 
length,  which  was  so  born,  and  gives  a  list  of  10  similar  instances  from  the 
literature  in  which  the  children  were  of  an  equal  or  greater  weight,  one 
among  them — Champion's  case — being  born  alive. 

Prognosis. — If  spontaneous  version  does  not  occur  within  the  first  few 
hours  after  the  onset  of  labour,  and  operative  procedures  are  not  instituted, 
the  outcome  for  both  mother  and  child  is  almost  uniformly  fatal,  the  child 
succumbing  to  asphyxia  and  the  mother  to  haemorrhage  or  infection,  as  a 
result  of  rupture  of  the  uterus.  On  the  other  hand,  if  appropriate  meas- 
45 


690 


OBSTETRICS 


ures  are  instituted  at  the  proper  time,  the  prognosis  for  the  child  is  fair, 
while  for  the  mother  it  is  excellent.  In  this  class  of  cases  prolapse  of  the 
cord  is  one  of  the  most  frequent  causes  of  foetal  death. 

Treatment. — If  the  diagnosis  has  been  made  in  the  last  month  of  preg- 
nancy and  the  pelvis  is  approximately  normal,  cephalic  version  should  be 
effected  by  external  manipulations,  and  the  child  held  in  its  new  position 
by  means  of  a  properly  fitting  bandage.  On  the  other  hand,  if  the  pelvis 
is  markedly  contracted,  such  a  procedure  is  not  advisable,  as  Csesarean  sec- 
tion will  probably  be  the  operation  of  choice. 

If  the  patient  is  not  seen  until  after  labour  has  set  in,  external  cephalic 
version  should  likewise  be  attempted,  provided  the  membranes  have  not 


Fig.  604. — Bare  Form  of  Sponta- 
neous Evolution  (Bumm). 


ruptured.  As  a  matter  of  fact, 
will  usually  prove  unsuccess- 
it  is  better  to  wait  until  the  cer- 
lated,  and  then,  after  ruptur- 
internal  podalic  version,  fol- 
On  the  other  hand,  if  the 
well  advanced  in  labour  and 
the  treatment  will  vary  ac- 
tation  of  the  cervix,  the  con- 
as    that    of    the    foetus    and 


however,  such  manipulations 
ful.  Under  these  circumstances 
vix  is  almost  completely  di- 
ing  the  membranes,  perform 
lowed  by  prompt  extraction, 
patient  be  not  seen  until  she  is 
the  membranes  have  ruptured, 
cording  to  the  degree  of  dila- 
dition  of  the  patient,  as  well 
uterus.     If  the  cervix  is  only 


partially  dilated,  while  the  child  is  alive  and  freely  movable  in  the  uterus, 
bipolar  version  may  be  attempted.  After  a  foot  has  been  brought  down 
the  cervix  should  be  allowed  to  dilate  still  further  before  extraction  is  com- 
pleted. On  the  other  hand,  if  the  condition  is  complicated  by  prolapse  of 
the  cord,  the  cervix  should  be  dilated  manually,  and  the  child  rapidly 
extracted  after  internal  podalic  version. 

Whenever  the  cervix  is  fully  dilated,  internal  podalic  version  should  be 
performed  at  once,  according  to  the  rules  already  given,  and  followed  by 
immediate  extraction,  provided  the  uterus  is  not  so  tightly  contracted  down 


DYSTOCIA    DTK  TO  COMPOUND   PRESENTATIONS  OF  FCETUS     691 

over  i  he  child  and  the  lower  uterine  segment  so  thinned  out  that  such  a  pro- 
cedure appears  synonymous  with  rupture.    In  such  cases,  anaesthesia  some- 
times so  relaxes  the  organ  that 
version  niav  lie  safely  effected, 
even  though  at   first  "-lance 


Fig.  ij05. — Frozen  Section  through  Woman  Dying  at  End  of  Pregnancy.    Compound 
Presentation.    (Braune.) 


"When  version  appears  to  be  contra-indicated,  decapitation  becomes  the 
operation  of  choice,  even  if  the  child  is  alive,  although  very  exceptionally 
Cesarean  section  might  be  thought  of  under  the  circumstances.  It  should 
not,  however,  be  undertaken  except 
at  the  express  wish  of  the  patient 
and  her  family,  and  then  only  after 
they  have  been  made  fully  conver- 
sant with  its  inherent  danger  in  the 
case  of  a  patient  who  in  all  prob- 
ability is  already  infected. 

Compound  Presentations.  —  By 
this  term  is  understood  the  pro- 
lapse of  an  extremity  alongside  of 
the  presenting  part,  both  entering 
the  pelvic  canal  simultaneously. 
It  is  not  an  infrequent  occurrence, 
being  observed  about  once  in  every 
250  cases  (Fig.  605). 

As  a  rule,  a  hand  or  an  arm 
comes  down  with  the  head;  much  less  commonly  both  arms,  or  a  hand  and 
a  foot,  or  both  feet  may  present  together.  Hahl  has  reported  a  case  in 
which  the  neck  of  the  child  was  girdled  by  its  legs,  so  that  the  scrotum  and 
head  were  felt  upon  vaginal  examination  (Fig.  606). 


Fig.  606. — Compound  Presentation  (Hahl). 


692  OBSTETRICS 

Some  idea  of  the  relative  frequency  of  the  different  combinations  may 
be  gained  from  the  following  table,  taken  from  Pernice: 

Head  and  hand 26  cases 

Head  and  arm 8 

Head,  hand,  and  cord 5     " 

Head  and  both  hands 4     ' 

Head,  one  hand,  and  one  foot 2     " 

Head,  two  hands,  one  foot,  and  cord 1  case 

Face,  hand,  and  cord 1     " 

Such  a  condition  is  frequently  associated  with  a  disproportion  between 
the  size  of  the  head  and  the  pelvis,  owing  to  which  early  engagement  has 
been  interfered  with,  and  as  a  result  one  or  more  of  the  extremities  have 
prolapsed  before  the  presenting  part  entered  the  pelvis. 

Treatment. — Whenever,  during  the  first  stage  of  labour,  a  hand  is  distin- 
guished alongside  of  the  head,  it  should  be  pushed  up  if  possible;  but  if 
it  be  firmly  fixed  between  the  head  and  the  pelvic  wall  it  should  be  left 
alone,  since  it  will  usually  not  interfere  with  labour.  On  the  other  hand, 
if  the  entire  arm  has  prolapsed  alongside  of  the  head,  an  energetic  effort 
should  be  made  to  replace  it.  If  this  is  not  possible,  version  should  be 
performed,  since  if  the  arm  retains  its  position  it  may  give  rise  to  serious 
dystocia,  more  especially  if  it  extends  around  the  child's  neck,  constituting 
the  so-called  nuchal  position. 

When,  as  happens  only  rarely,  the  foot  prolapses,  attempts  should  be 
made  to  replace  it;  if  these  fail,  version  should  be  resorted  to. 

LITERATURE 

Ballantyne.     General  Foetal  Cystic  Elephantiasis.      The  Diseases  of  the  Foetus,  Edin- 
burgh, 1892,  i,  182-219. 
Bartholin.     Quoted  by  Payer. 

Brouha.     Du  rein  polykystique  congenital.     Revue  de  Gyn..  1901,  v,  231. 
Hanau.     Ueber  congenitale  Cystenniei-en.     D.  I.,  Giessen,  1890. 

Hahl.     Strictur des  os  internum als  Geburtshinderniss.    Archiv  f.  Gyn.,  1901,  lxiii,  684-694. 
Mirabeau.     Beitrag  zur  Lehre  von  der  fotalen  Cystenniere.     Monatsschr.  f.  Geb.  u.  Gyn., 

1900,  si,  216-237. 
Payer.    Zur  Lehre  von  der  Selbstentwickelung.     Volkmann's  Sammlung  kirn.  Vortrage, 

N.  F.,  1901,  Nr.  314. 
Pernice.     Die  Geburt  mit  Vorfall  der  Extremitaten  neben  dem  Kopfe.     Leipzig,  1858. 
Phaenomenow.     Beitrag  zur  Casuistik  der  durch  die  Frucht  bedingten  Geburtshinder- 

nisse.     Archiv  f.  Gyn.,  1881,  xvii,  133-139. 
Porak  et  Couvelaire.      Foie  polykystique  cause  de  dystocie.      Comptes  rendus  Soc. 

d'Obst.,  de  Gyn.  et  de  Pasd.  de  Paris.  1901.  iii,  26-37. 
Resnikow.     Vierjahrige  Retention  in  utero  eines  Skeletes  der  im  7.  Monate  der  Schwan- 

gerschaft  abgestorbenen  Frucht.     Centralbl.  f.  Gyn.,  1895,  244-247. 
Roederer.     Quoted  by  Payer. 

Schroeder,  Olshausen  und  Veit.     Lehrbuch  der  Geburtshulfe.  XIII.  Ann.,  1899,  737. 
Schwyzer.      Ueber   einen    Fall    von    Geburtshinderniss,    bedingt    durch   hochgradige 

Eierweiterung  der  fotalen  Harnblase.     Archiv  f.  Gyn..  1893.  xliii,  333-346. 
Theilhaber.     Ein  Fall  von  Cystenniere.     Monatsschr.  f.  Geb.  u.  Gyn.,  1899,  ix,  496-504. 
Walther.     Dystokie  infolge  ubermassiger  Ausdehnung  der  fotalen  Harnblase.     Zeitschr. 

f.  Geb.  u.  Gyn.,  1893,  xxvii,  333-347. 


CHAPTER    XL 
ECLAMPSIA 

Eclampsia  is  an  acute  disease  which  may  occur  in  the  pregnant;,  par- 
turient, or  puerperal  woman,  and  is  characterized  by  clonic  and  tonic  con- 
vulsions, during  which  there  is  loss  of  consciousness  followed  by  more  or 
less  prolonged  coma. 

Frequency. — Statistical  tables  go  to  show  that  eclampsia  occurs  about 
once  in  every  500  labours,  but  it  is  almost  impossible  to  determine  its  fre- 
quency with  any  degree  of  exactness,  inasmuch  as  few  practitioners  see  a 
sufficiently  comprehensive  series  of  cases  in  private  practice  to  permit  of 
trustworthy  conclusions;  while,  on  the  other  hand,  hospital  records  by 
themselves  give  an  exaggerated  idea  of  its  frequency,  for  the  reason  that 
many  of  the  patients  would  have  remained  at  home  unless  they  had  had 
convulsions.  The  following  table  would  indicate  that  eclampsia  occurs  in 
about  0.75  per  cent  of  the  women  entering  lying-in  hospitals — once  in 
133  cases: 

Goldberg  (Dresden.  1891)  in  10,717  labours,  81  cases  of  eclampsia  (0.75$) 
Cassamayor  (Paris,  1892)     i;  16,225        1;        99  "  "  (0.61#) 

Green  (Boston,  1892)  "    3,500        "        36  "  "  (lg) 

Knapp  (Prag,  1900)  "     7,636        "        41  "  "  (0.53£) 

Xewell  (Boston,  1900)  "     6,700        "        99  "  "  (\M%) 

The  larger  tabulations  made  by  Lohlein  in  1891,  and  by  Veit  in  1896, 
which  are  based  upon  statistics  from  the  various  clinics  in  Germany,  afford 
almost  the  same  conclusions.  In  the  former  there  were  325  instances  of 
eclampsia  in  15,328  cases,  and  in  the  latter  905  in  149,366  cases — a  per- 
centage of  0.62  and  0.60  respectively — 1  in  160  and  1  in  166.  These  sta- 
tistics include  all  cases  of  eclampsia,  but  Lohlein  differentiated  between  the 
total  number  of  cases  and  those  occurring  in  patients  who  were  in  the 
hospital  at  the  onset  of  the  disorder,  and  found  that  in  the  latter  the  ratio 
was  only  0.3  per  cent — one  in  330. 

Eclampsia  varies  markedly  in  frequency  at  different  times,  Cassamayor 
stating  that  in  Tarniers  clinic  in  Paris  it  was  observed  many  times  more 
frequently  in  some  years  than  in  others.  Thus,  in  1872.  there  was  1  case 
to  every  IT  labours,  as  compared  with  1  to  730  and  1  to  130  in  the  years 
1882  and  1891  respectively. 

Clinical.  History. — Zweifel  has  reported  a  case  of  eclampsia  occurring  in 
the  third  month,  but  as  a  rule  it  is  not  encountered  before  the  second  half 
of  pregnancy,  and  becomes  more  frequent  the  nearer  term  is  approached. 

693 


694  OBSTETRICS 

It  is  generally  stated  that  70  to  80  per  cent  of  all  cases  occur  inprimip- 
arous  women,  Knapp,  Olshausen,  Cassamayor,  and  Goldberg  reporting  a 
proportion  of  71,  75,  77,  and  86.4  per  cent  respectively.  In  all  probability 
these  figures  are  somewhat  too  high,  inasmuch  as  they  are  based  upon  hos- 
pital practice.  Nevertheless,  be  this  as  it  may,  it  is  certain  that  in  the 
main  primiparous  women  are  much  more  liable  to  the  disorder. 

Twin  pregnancy  and  hvdramnios  appear  to  act  as  predisposing  factors, 
the  former  condition  being  noted  by  Olshausen  and  Cassamayor  in  8  and 
5.7  per  cent  of  their  cases  of  eclampsia  respectively,  whereas  for  all  labours 
the  usual  ratio  is  1.5  per  cent.  It  is  possible  that  heredity  sometimes  plays 
a  part  in  its  production,  and  Elliot,  Olshausen,  and  Pinard  have  reported 
cases  which  apparently  confirm  this  view. 

An  eclamptic  convulsion  sometimes  occurs  without  warning,  "like  a 
bolt  from  a  clear  sky,"  in  women  who  are  apparently  in  perfect  health. 
In  the  majority  of  cases,  however,  the  outbreak  is  preceded  for  a  longer 
or  shorter  period  by  premonitory  symptoms  indicative  of  the  toxaemia  of 
pregnancy,  among  the  more  common  being  oedema,  headache,  epigastric 
pain,  and  possibly  disturbances  of  vision.  At  the  same  time  the  urine 
becomes  decreased  in  quantity,  while  albumin  and  casts  and  a  marked  dimi- 
nution in  the  amount  of  urea  are  demonstrable. 

The  attack  may  come  on  at  any  time,  sometimes  while  the  patient  is 
sleeping.  If  she  is  awake,  the  first  sign  of  the  impending  convulsion  is  a 
fixed  expression  of  the  ey_es,  which  soon  begin  to  roll  from  side  to  side. 
The  pupils  are  usually  dilated,  less  often  contracted.  The  convulsive 
movements  appear  first  about  the  mouth,  which  begins  to  twitcrTand  is 
drawrTto  one  side,  the  entire  face  becoming  distorted.  They  extend 
rapidly  to  the  arms,  the  body,  and  finally  to  the  legs.  They  are  usually 
clonic  in  character,  though  sometimes  they  take  on  a  tonic  form  and  the 
patient  becomes  rigid.  The  breathing  is  stertorous,  the  face  congested,  and 
flushed,  the  patient  foams  at  the  mouth,  and  often  bites  her  tongue.  Dur- 
ing the  convulsion,  which  may  last  for  a  few  seconds  to  two  minutes,  the 
woman  is  profoundly  unconscious,  and  after  the  movements  cease  passes 
into  a  condition  of  coma  which  lasts  for  a  longer  or  shorter  period. 

More  particularly  when  the  disorder  appears  in  the  latter  part  of  labour 
or  during  the  puerperium,  a  single  convulsion  only  may  be  observed,  an 
uninterrupted  recovery  ensuing  after  the  patient  emerges  from  the  coma. 
Oftener,  however,  the  first  is  the  forerunner  of  other  convulsions,  which 
may  vary  in  number  from  1  to  2  in  mild,  to  100  or  more  in  fatal  cases, 
the  intervals  between  them  becoming  shorter-  in  inverse  proportion  to  the 
number.  In  rare  instances  they  follow  one  another  so  rapidly  that  the  pa- 
tient appears  to  be  in  a  prolonged,  almost  continuous  convulsion. 

The  duration  of  the  coma  is  very  variable.  When  the  convulsions  are 
infrequent,  the  patient  usually  recovers  consciousness  after  each  attack, 
while  in  severe  cases  the  coma  persists  from  one  convulsion  to  another, 
and  death  may  result  without  any  awakening  from  it.  In  rare  instances  a 
single  convulsion  may  be  followed  by  profound  coma,  from  which  the 
patient  never  emerges,  though,  as  a  rule,  death  does  not  occur  until  after  a 
frequent  repetition  of  the  convulsive  attacks.     The  immediate  cause  of 


ECLAMPSIA  C95 

death  is  usually  oedema  of  the  lungs  or  apoplexy,  though  if  the  fatal  issue  Is 
postponed  for  several  days,  ii  is  usually  attributable  to  an  aspiration  pneu- 
monia  or  a  puerperal  infection. 

Th  most  cases  during  the  seizure  the  arterial  pressure  is  markedly 
increased,  and  the  pulse  is  full  and  bounding!  In  seven-  cases,  ho, 
it  is  weaker  and  more  vapid,  becoming  more  compressible  ami  filiform  with 
each  succeeding  convulsion,  in  many  eases  the  temperature  rises  to  a  very 
considerable  height  from  the  onset  of  the  disease  and  gradually  falls  as 
the  patient  improves;  sometimes,  however,  it  remains  normal.  A  tempera- 
i  are  of  104  or  105  degrees  is  not  unusual,  and  in  fatal  cases  it  may  reach  107 
or  108  degrees  just  before  the  end.  As  regards  the  cause  of  this  elevation. 
there  is  much  discrepancy  of  opinion.  Olshausen  believes  that  the  poison 
which  gives  rise  to  the  eclampsia  also  stimulates  the  thermal  centres,  while 
Zweifel  holds  that  the  fever  is  nearly  always  of  infectious  origin.  The  fact 
that  the  uterine  lochia  have  been  found  to  be  perfectly  sterile  in  a  number 
of  cases  speaks  against  infection  being  the  sole  cause,  but  that  it  is  often 
responsible,  especially  in  those  cases  in  which  the  fever  persists  for  days 
after  the  cessation  of  the  seizures,  there  can  be  but  little  doubt.  Moreover, 
it  would  seem  that  women  suffering  from  eclampsia  are  more  susceptible 
to  infection  than  usual. 

According  as  the  disorder  first  appears  before  or  during  labour  or  in  the 
first  hours  of  the  puerperium,  it  is  designated  as  ante-partum,  intra-partum, 
or  post-partum  eclampsia.  It  is  generally  stated  in  the  text-books  that  the 
last  is  the  least  common;  but  that  the  conclusions  as  to  the  relative  inci- 
dence of  the  different  varieties  are  by  no  means  unanimous  is  shown  by 
the  following  table: 

Ante-partum.  Intrapartum.         Post-partum. 

Olshausen 40#  46#  14$ 

Knapp 24.5#  60.9<?  14.6g 

Goldberg 26£  57#  11% 

Green 36#  22#  42$ 

Newell  states  that  one  third  of  his  cases  occurred  after  the  birth  of  the 
child.  Personally,  I  have  observed  the  post-partum  variety  in  only  a  few 
instances. 

It  would  appear  from  the  statistics  of  three  of  the  authors  just  cited, 
that  ante-partum  eclampsia  occurs  less  frequently  than  the  intra-partum 
variety,  but  my  own  figures  would  be  more  nearly  in  accord  with  thorn 
than  those  of  Green.  Olshausen  has  reached  a  similar  conclusion,  and  con- 
siders that  the  contrary  statements  of  most  authors  are  due  to  the  fact  that 
they  have  failed  to  remember  that  in  the  majority  of  cases  uterine  contrac- 
tions set  in  with  the  first  convulsion,  so  that  if  the  patient  is  not  seen  before 
the  seizure  it  is  often  very  difficult  to  determine  with  which  variety  one 
has  to  deal. 

Ante-partum  eclampsia  may  terminate  in  several  ways.  As  a  rule,  labour 
sets  in  and  a  premature  child  is  born  spontaneously,  or  the  uterus  is 
emptied  by  operative  procedures.  Sometimes  the  patient  dies  undelivered. 
TrTa  small  number  of  cases  labour  does  not  supervene,  and  if  the  woman 
survives  the  attack  she  may  ffive  birth  to  a  dead  or  macerated  foetus  some 


696  OBSTETRICS 

time  afterward.  In  such  cases  it  is  believed  that  its  death  is  the  direct  re- 
sult of  the  eclampsia.  Now  and  again  the  patient  may  recover  from  the 
attack  and  give  birth  to  a  living  child  at  term,  while  in  very  exceptional 
cases,  after  being  perfectly  well  for  a  longer  or  shorter  period,  she  may 
have  a  recnrrence_of  the  seizure,  which  may  terminate  in  any  one  of  the 
ways  mentioned  above.  Such  cases  have  been  described  by  Leudet,  Ols- 
hausen,  and  Lafon. 

If  the  attack  occurs  during  labour,  the  pains  usually  increase  in  fre- 
quency and  severity,  so  that  the  child  will  be  born  somewhat  sooner  than 
usual,  after  which  the  convulsions  generally  cease.  On  the  other  hand, 
in  severe  cases,  or  when  there  is  some  impediment  causing  dystocia,  the 
patient  may  die  undelivered,  unless  operative  measures  are  undertaken. 

In  post-partum  eclampsia  the  attack  usually  comes  on  soon  after  de- 
livery, ancTrecovery  often  occurs  after  a  single  convulsion.  In  other  cases, 
however,  the  seizures  follow  one  another  in  rapid  succession,  and  occa- 
sionally cause  death.  The  general  belief  that  cases  of  this  variety  are 
comparatively  benign  is  denied  by  Olshausen,  who  noted  a  mortality  of  25 
per  cent. 

A  few  instances  have  been  reported  in  which  the  disorder  did  not 
appear  until  several  weeks  after  the  birth  of  the  child.  It  is  probable,  as 
has  been  pointed  out  by  Van  der  Velde,  that  the  vast  majority  of  such 
cases  were  not  eclamptic  at  all,  but  that  the  seizures  were  clue  to  other 
causes. 

In  rare  instances  the  onset  is  preceded  by  a  distinct  aura  (Olshausen), 
but  this  is  usually  lacking,  the  convulsion  coming  on  either  without  warn- 
ing or  after  the  appearance  of  symptoms  indicative  of  the  toxaemia  of  preg- 
nancy. As  has  been  pointed  out  by  Olshausen,  severe  epigastric  pain  is 
a  frequent  precursor  of  the  seizure,  and  is  a  sign  to  which  too  much  attention 
can  hardly  be  paid. 

The  convulsions  are  always  followed  by  unconsciousness,  and,  moreover, 
the  patient  may  not  only  not  remember  the  attack  itself,  but  even  have  no 
recollection  of  occurrences  which  have  taken  place  several  hours  previous 
to  it.  This  is  a  not  altogether  uncommon  observation,  and  may  sometimes 
have  an  important  bearing  from  a  medico-legal  point  of  view. 

In  5  per  cent  of  Lohlein's  and  in  13  per  cent  of  Knapp's  cases  eclampsia 
was  followed  by  marked  mental  derangejnejit.  My  own  observations  lead 
me  to  believe  that  the  experience  of  these  authors  was  exceptional,  although 
it  must  not  be  forgotten  that  mental  derangement  following  eclamptic 
convulsions  is  one  of  the  well-recognised  varieties  of  puerperal  insanity; 
but  whether  it  is  a  direct  result  of  the  disease  or  is  due  indirectly  to  infec- 
tion has  not  yet  been  demonstrated. 

In  rare  instances,  as  the  result  of  permanent  cerebral  lesions  incident 
to  eclampsia,  a  liemianojma  may  develop  during  the  puerperium.  A  case 
of  this  character,  occurring  in  my  practice,  was  reported  in  detail  by  Woods 
at  the  1902  meeting  of  the  American  Ophthalmological  Society. 

More  frequently  the  patient  suffers  from  disturbed  vision  during  the 
latter  part  of  pregnancy,  due  to  an  albuminuric  retinitis.  As  this  is  an 
accompaniment  of  an  acute  nephritis,  eclampsia  does~not  always  develop. 


ECLAMPSIA 


15! » 7 


The  outcome  in  such  cases  is  dependent  upon  the  further  course  of  the  un- 
derlying disease.  In  other  cases  the  visual  disturbance  is  unattended  by 
demonstrable  changes  in  bhe  retina  or  optic  nerve,  ami  is  to  be  regarded 
merely  as  a  manifestation  of  the  general  toxaemia,  complete  recovery  usually 
following  within  a  few  days  after  the  termination  of  pregnancy. 

In  a  small  number  of  cases  the  patient  becomes  markedly  jaundiced, 
either  during  or  just  after  the  convulsive  seizure.  This  sign  is  of  grave 
prognostic  significance,  and  indicates  serious  hepatic  lesions. 


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Fig.  607. — Ueea  Chart. 

Eclampsia  followed  by  recovery.  Chart  shows  marked  quantity  of  albumin  and  almost  total  absence 
of  urea  at  time  of  convulsions,  with  rapid  disappearance  of  the  former  and  immense  increase 
in  the  amount  of  the  latter  in  the  following  days. 

Eclampsia  may  occur  not  only  during  the  course  of  an  ordinary  gesta- 
tion, but  was  observed  by  Maygrier  in  the  false  labour  accompanying  extra- 
uterine pregnancy. 

During  the   eclamptic   attack  the   urine  is   markedly   diminished    in 


698 


OBSTETRICS 


amount,  is  loaded  with  tube  casts  and  often  contains  a  considerable  quan- 
tity  ol  blood,  while  occasionally  the  secretion  is  entirely  suppressed.  Chem- 
ical examination  nearly  always  reveals  the  presence  of  an  abundance  of 
albumin  and  a  notable  diminution  in  the  amount  of  urea.  After  the  ter- 
mrnaiion  of  the  convulsions,  in  favourable  cases,  there  is  a  rapid  increase 
in  the  amount  of  urine  and  urea,  together  with  a  decrease  in  the  amount  of 


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AMOUNT  OF 
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Fig.  608.— IJeea  Chart. 

Eclampsia  followed  "by  death.     Chart  shows  almost  total  disappearance  of  urea  at  time  of  convul- 
sions, with  rapid  rise  the  following  day,  followed  "by  a  progressive  fall  as  death  approached. 

albjmjin.  In  the  majority  of  cases  the  urine  rapidly  becomes  normal,  and 
within  a  few  weeks  gives  no  evidence  of  the  previous  pathological  condition. 
On  the  other  hand,  it  sometimes  contains  albumin  and  casts  for  months  after 
delivery — a  finding  that  indicates  the  existence  of  a  chronic  renal  lesion, 
which,  as  a  rule,  has  been  present  before  the  eclamptic  attack,  although 
occasionally  the  nephritis  appears  to  have  been  a  direct  result  of  the  eclamp- 
sia.   (See  Figs.  607  and  608.) 


ECLAMPSIA  699 

Pathology. — After  Rayer  and  Lever  had  demonstrated  the  presence  of 
albumin  in  the  urine  of  women  suffering  from  lids  disorder,  it  was  generally 
believed  that  the  fundamental  pathological  Lesion  in  eclampsia  was  a  neph- 
ritis, and  for  a  long  time  the  condition  was  considered  to  be  identical 
with  unvmia. 

This  view,  however,  was  gradually  abandoned  when  ii  was  found  thai 
only  a  small  proportion  of  the  women  suffering  from  chronic  nephritis  had 
eclampsia;  and  still  further  modifications  became  necessary  after  it  had 
been  shown  that  the  urine  did  not  necessarily  contain  albumin  at  the  time 
of  the  eclamptic  attack,  Schroeder,  Ingerslev,  and  Charpentier  having  col- 
lected respectively  62,  112,  and  143  such  cases  from  the  literature.  Its  ab- 
sence, however,  docs  not  necessarily  disprove  the  renal  origin  of  the  disease, 
since  Van  der  Yelde  has  reported  two  instances  of  eclampsia  in  which  the 
kidneys  were  markedly  diseased,  notwithstanding  the  fact  that  albumin 
was  not  demonstrable  in  the  urine. 

For  the  most  part,  autopsy  will  reveal  the  presence  of  renal  changes, 
which  may  be  very  marked  in  some  and  only  slight  in  other  cases.  The 
lesions  are  usually  those  of  an  acute  nephritis  with  marked  necrosis  of  the 
renal  epithelium.  Ordinarily,  this  is  the  only  lesion,  though  occasionally 
it  may  be  engrafted  upon  a  chronic  process.  Prutz  found  kidney  changes 
in  all  but  7  out  of  368  cases  collected  from  the  literature,  in  which  the 
description  was  sufficiently  accurate  to  be  of  value.  Forms  of  acute  or 
chronic  nephritis  were  present  in  46  and  11.6  per  cent  of  his  cases  respective- 
ly, while  degenerative  changes  were  observed  more  frequently.  His  conclu- 
sions are  stated  as  follows:  "  Notwithstanding  the  frequency  of  renal  lesions, 
we  are  not  justified,  even  in  the  majority  of  cases,  in  considering  them  as 
the  anatomical  substratum  of  eclampsia,  for  in  many  instances  they  are  too 
insignificant;  accordingly,  it  must  remain  a  question  whether  they  are  not 
purely  secondary  in  the  greater  proportion  of  the  cases." 

More  or  less  similar  results  were  obtained  by  Olshausen,  Goldberg, 
Hughes  and  Carter,  Lubarsch  and  Schmorl,  all  of  whom  stated  that  renal 
lesions  were  absent  in  a  small  |)roportion  of  their  cases.  Moreover,  Bouffe 
de  Saint  Blaise,  after  studying  the  condition  of  the  kidneys  in  40  cases  of 
eclampsia,  states  that  these  organs  are  often  perfectly  normal,  and  that  the 
lesions  when  present  should  be  considered  as  secondary.  On  the  other 
hand,  Pels  Leusden,  Winckler,  and  Knapp  observed  pronounced  renal 
changes  in  all  of  their  cases,  and  were  inclined  to  consider  them  as  the 
characteristic  lesion  of  the  disease. 

.  Guenard  and  Potocki  attempted  to  determine  the  permeability  of  the 
kidneys  by  administering  methylene  blue  to  7  eclamptic  patients.  As  the 
drug  could  always  be  demonstrated  in  the  urine  a  short  time  after  its  ad- 
ministration, they  concluded  that  the  renal  function  was  not  markedly  im- 
paired, even  though  anatomical  lesions  might  be  present. 

On  the  whole,  the  evidence  at  hand  would  seem  to  indicate  that  renal 
changes,  while  almost  constantly  present,  are  not,  as  a  rule,  sufficiently 
marked  to  justify  one  in  considering  them  as  the  characteristic  lesion  of 
eclampsia,  which  must  therefore  be  sought  in  some  other  organ. 

Halbertsma,  in  1876,  pointed  out  that  the  ureters  were  often  enlarged 


700  OBSTETRICS 

and  dilated,  and  was  inclined  to  attribute  the  production  of  the  disease  to 
this  condition.  Prutz  noted  a  similar  finding  37  times  in  his  analysis  of 
500  autopsies. 

In  1886,  Jtirgens  and  Klebs  pointed  out  the  existence  of  a  licemorrhagic 
hepatitis  in  certain  cases  of  eclampsia.  Their  observations,  however,  cre- 
ated very  little  interest,  and  it  remained  for  Pilliet,  in  1888,  to  direct  our 
attention  to  certain  hamiorrhagic  lesions  in  the  eclamptic  liver.  His  work 
was  abundantly  confirmed  by  Schmorl,  who  in  a  monograph  published  in 
1893,  and  based  upon  the  autopsies  of  17  women  dead  of  eclampsia,  stated 
that  he  had  found  in  every  case  lesions  of  the  liver  which  he  held  to  be 
more  characteristic  than  those  observed  in  the  kidneys.  These  consist  of 
irregularly  shaped,  reddish  or  whitish  areas  scattered  through  the  entire 
organ,  but  more  particularly  in  the  iielgnbourhood  of  the  smaller  portal 
vessels.  They  are  readily  seen  with  the  naked  eye,  and  on  section  give  the 
liver  a  mottled  appearance.  Cnder  the  microscope  they  arc  recognised  as 
areas  of  necrosis,  in  which  blood-cells  may  or  may  nm  be  present.  Schmorl 
attributed  their  formation  to  degenerative  changes  following  thrombotic 


Fig.  609. — Area  of  Necrosis  in  Eclamptic  Liver.     X  90. 

processes  in  the  smaller  portal  vessels,  and  considered  that  their  presence 
justified  the  diagnosis  of  eclampsia  without  further  knowledge  of  the  his- 
tory of  the  case  (Fig.  609). 

These  results  were  soon  confirmed  by  Lubarsch,  Prutz,  Bar  and  Guyeisse, 
Bouffe  de  Saint  Blaise,  and  many  others,  the  last-named  observer  having 


ECLAMPSIA  T01 

demonstrated  them  in  42  consecutive  cases,  while  Schmorl,  in  1902,  found 
them  in  71  out  of  73  autopsies.  I  have  been  able  to  demonstrate  similar 
lesions  in  all  the  eclamptic  livers  which  1  have  examined,  ^though  rarely 
so  pronounced  as  described  by  Schmorl.     Indeed,  in  several    specimens 

they  could  be  identified  only  with  the  aid  of  the  microscope.  At  the  same 
time  they  are  extremely  characteristic,  am!,  as  the  researches  of  Schmorl 


Fig.  610. — Placental  Giant  Cell  and  Chorionic  Villus  in  Blood-vessel  of  Tube  Wall 
Some  Distance  from  Placental  Site.     X  80. 

show  that  they  do  not  occur  with  such  regularity  in  any  other  disease,  it 
must  be  admitted  that  they  are  intimately  connected  with  eclampsia, 
although,  as  will  be  indicated,  later,  they  cannot  be  regarded  as  its  primary 
cause. 

The  hepatic  changes  are  so  characteristic  and  constant  that  Bouffe  de 
Saint  Blaise  and  many  French  observers  believe  that  they  represent  the 
primary  lesion  of  the  disease,  and  consider  that  the  entire  process  is  due 
to  an  impairment  of  the  hepatic  function — a  liepato-toxcpmia. 

Several  observers  have  described  the  presence  of  hamiatomata  of  vary- 
ing size,  just  beneath  the  capsule  of  the  liver,  Prutz  having  recorded  a 
fatal  haemorrhage  from  the  rupture  of  such  a  structure  into  the  peritoneal 
cavity. 

Various  statements  have  been  made  concerning  the  pathological  findings 
in  the  brain — cedema,  hypera?mia,  thrombosis,  and  apoplexy  being  described 
as  the  main  lesions.  Prutz  noted  cedema  in  42  per  cent,  hyperemia  in  35 
per  cent,  and  apoplexy  in  13  per  cent,  while  the  brain  was  apparently  nor- 
mal in  10  per  cent  of  his  cases.  Schmorl,  in  58  out  of  65  autopsies, 
in  which  the  organ  was  examined,  noted  the  presence  of  thrombi  in  the 
smaller  cerebral  vessels,  and  regarded  them  as  the  cause  of  the  small  areas 
of  necrosis  which  are  so  often  observed. 


702  OBSTETRICS 

Marked  degenerative  changes  are  often  noticed  in  the  myocardium, 
which  Schmorl  regards  as  secondary  lesions  resulting  from  the  prolonged 
use  of  chloroform  in  the  treatment  of  the  disease. 

Most  recent  observers,  notably  Schmorl  and  Winckler,  have  demon- 
strated the  presence  of  giant  cells  in  the  pulmonary  capillaries  which  they 
have  identified  with  the  so-called  giant  ceils  of  the  placenta — namely, 
masses  of  syncytium.  Schmorl  formerly  believed  that  their  presence  prob- 
ably explained  the  origin  of  the  thrombotic  processes  observed  in  various 
organs.  But  at  present  they  are  regarded  as  having  no  significance,  as  they 
are  frequently  found  in  pregnant  women  dead  of  other  diseases.  I  have 
frequently  seen  similar  giant  cells  and  even  portions  of  chorionic  villi  in 
the  vessels  of  the  uterus  in  cases  of  normal  gestation,  and  in  those  of  the 
tube  in  extra-uterine  pregnancy  (Fig.  610). 

In  patients  who  have  died  several  days  after  the  cessation  of  the  con- 
vulsions, in  addition  to  the  lesions  just  described,  broncho-pneumonia  or 
various  evidences  of  puerperal  infection  are  frequently  noted. 

It  is  apparent,  therefore,  that  the  main  lesions  in  eclampsia  are  found 
in  the  kidneys,  liver,  and  brain;  but  in  view  of  the  marked  discrepancy  in 
the  statements  oi  the  various  authors  concerning  their  relative  frequency 
and  importance,  it  would  seem  that  the  anatomical  changes  are  not  con- 
stant, although  those  in  the  liver  are  the  most  characteristic.  Accord- 
ingly, we  are  forced  to  conclude  either  that  under  the  term  eclampsia 
are  included  a  number  of  different  disease  entities,  each  with  their  own 
anatomical  lesions;  or,  what  is  more  probable,  that  the  morbid  process  is 
caused  by  some  as  yet  unknown  poisonous  substance  circulating  in  the 
blood  which  may  give  rise  to  lesions  of  varying  intensity  in  the  several 
organs. 

JEtiohgy. — So  many  hypotheses  have  been  advanced  concerning  the  aeti- 
ology of  eclampsia  that  Zweif  el  has  aptly  designated  it  as  "  the  disease  of 
theories."     Unfortunately,  exact  knowledge  is  still  lacking. 

From  the  earliest  periods  it  was  considered  as  a  disorder.  _pf  the  nervous 
system  peculiar  to  pregnancy.  This  conception  is  no  longer  entertained, 
though  there  is  no  doubt  that  the  nervous  system  is  in  a  condition  of  far 
less  stable  equilibrium  during  pregnancy  than  at  other  times.  This  fact 
has  been  conclusively  demonstrated  by  Blumreich  and  Zuntz,  who  showed 
that  convulsions  could  be  produced  by  the  application  of  far  smaller  quanti- 
ties of  powdered  creatinin  to  the  cerebral  cortex  in  pregnant  than  in  non- 
pregnant animals. 

This  theory  was  to  a  certain  extent  rehabilitated  in  1892  by  Herff,  who 
held  that,  owing  to  a  faulty  development  of  the  nervous  system,  a  certain 
number  of  women  are  particularly  prcme  to  eclampsia,  so  that  conditions 
which  in  healthy  individuals  are  of  but  little  significance  would  be  sufficient 
to  give  rise  to  the  disease. 

As  a  result  of  the  work  of  Lever,  eclampsia  was  identified  with  uraemia, 
and  this  view  was  only  slowly  abandoned  after  it  had  been  conclusively  dem- 
onstrated that  the  two  conditions  had  but  little  in  common. 

Spiegelberg,  in  1870,  advanced  the  theory  that  the  circulation  of  ammo- 
nium carbonate  in  the  blood  was  responsible  for  the  seizures,  but,  chemical 


ECLAMPSIA  703 

analysis  having  failed  to  substantiate  this  statement,  the  idea  was  soon 
abandoned. 

The  Traube-Eosenstein  theory,  which  held  that  the  convulsions  were 
the  result  of  ana?mia  and  oedema  of  the  brain,  found  widespread  accept- 
ance for  many  years,  but  was  ultimately  abandoned  in  view  of  the  fact  that 
such  conditions  could  not  be  demonstrated  at  antopsy  in  the  majority 
of  cases. 

Delore  and  Eodet,  of  Lyons,  in  188-t,  suggested  bacterial  invasion  as  a 
possible  etiological  factor,  but  adduced  no  evidence  in  support  of  such  a 
view.  The  first  investigations  were  made  by  Doleris  in  1885.  Following 
him  a  number  of  other  observers,  among  whom  may  be  mentioned  Blanc, 
Combemale  and  Bue,  Favre,  Gley,  Gerdes,  Herrgott,  Sourel,  and  Levino- 
witch.  published  work  on  similar  lines.  They  cultivated  various  bacteria 
from  the  blood,  urine,  and  tissues  of  eclamptic  women,  but  their  results 
were  so  contradictory  as  to  be  of  but  little  value.  On  the  other  hand, 
Haegler,  Doderlein,  Schmorl,  Lubarsch  and  Bar  and  Guyeisse,  after  find- 
ing that  careful  bacteriological  examination  of  the  fluids  and  tissues  of 
women  dead  of  eclampsia  gave  uniformly  negative  results,  felt  justified  in 
asserting  that  the  micro-organisms  described  by  other  observers  could  not 
be  considered  as  ^etiological  factors. 

~SLy  own  investigations  have  been  confirmatory  of  these  latter  observers, 
and  up  to  the  present  time  satisfactory  proof  has  not  been  adduced  in 
support  of  the  bacterial  nature  of  eclampsia,  nor  does  it  seem  likely  to  be 
forthcoming. 

A  much  more  promising  field  of  investigation  was  opened  up  by  the  work 
of  Bouchard  upon  auto-intoxication.  Eiviere,  in  1888,  was  the  first  to  put 
forward  the  theory  that  eclampsia  was  an  auto-intoxication  resulting  from 
the  heaping  up  of  some  substance  in  the  system  dunnj_^regnancy,  holding 
that  its  presence  was  indicated  by  an  increase  in  the  toxicity  of  the  blood 
serum  and  a  decrease  in  that  of  the  urine. 

This  conception  was  placed  upon  an  apparently  solid  foundation  by 
the  work  of  Chamberlent  and  Tarnier  and  their  students,  who  showed 
that  in  a  number  of  cases  the  urine  of  women  suffering  from  eclampsia,  or 
just  about  to  be  attacked  by  it,  was  far  less  toxic  than  usual,  while  the 
toxicity  of  the  blood  serum  was  markedly  increased.  They  concluded, 
therefore,  that  some  poisonous  substance,  which  should  have  been  excreted 
by  the  kidneys,  was  accumulating  in  the  system  and  thereby  increasing  the 
toxicity  of  the  blood  serum,  which  in  turn  gave  rise  to  the  renal  and 
hepatic  lesions  which  still  further  accentuated  the  condition. 

Their  investigations  were  apparently  confirmed  by  the  work  of  Ludwig 
and  Savor,  who  considered  the  offending  product  to  be  carbamic  acid,  which 
they  believed  was  formed  as  the  result  of  imperfect  metabolic  processes, 
especially  in  the  liver.  The  most  enthusiastic  advocates  of  this  theory 
are  the  students  of  Pinard.  Thus,  Bouffe  de  Saint  Blaise  considers  that 
the  main  feature  of  the  disease  is  an  alteration  in  the  function  of  the  liver, 
which  fails  to  render  innocuous  certain  poisonous  products  of  metabolism 
during  their  passage  through  it.  and  that  these  in  turn  give  rise  to  an  auto- 
intoxication which  is  designated  as  liepato-toxcemia.     When  the  disturbance 


704  OBSTETRICS 

is  slight,  the  patient  merely  suffers  from  nausea  or  headache;  hut  when  it  is 
marked,  secondary  renal  changes  develop  which  in  turn  lead  to  a  still  further 
retention  of  the  poison  and  the  ultimate  production  of  eclampsia. 

The  studies  of  Volhard  in  1897  failed  to  substantiate  this  theory,  as  he 
was  unable  to  show  that  the  blood  serum  was  more  toxic  in  eclampsia  than 
in  other  conditions.  Moreover,  the  doctrine  in  general  has  received  a 
severe  blow  from  the  work  of  Van  der  Bergh,  Forchheimer,  Stewart,  and 
Schumacher,  which  showed  the  results  obtained  by  the  injection  of  blood 
serum  and  urine  into  animals  to  be  so  variable  and  dependent  upon  so  many 
factors  that  they  must  be  received  with  the  greatest  caution. 

Their  experiments  proved  that  death  depends  in  great  part  upon  the 
rapidity  with  which  the  injection  is  made  rather  than  upon  the  toxicity 
of  the  fluid  injected.  Moreover,  Schumacher  and  Stewart  have  demon- 
strated that  a  large  part  of  the  urinary  toxicity  is  due  to  bacterial  products 
rather  than  to  the  presence  of  a  definite  organic  poison  in  the  urine,  since 
they  found  that  large  quantities  could  be  injected  into  animals  with  almost 
perfect  impunity,  provided  the  urine  is  thoroughly  sterilized;  whereas,  if 
such  precautions  are  not  taken,  small  quantities  of  the  same  urine  led  to 
uniformly  fatal  results. 

The  present  status  of  the  question  may  therefore  be  summarized  as 
follows:  The  clinical  history  and  anatomical  findings  afford  presumptive 
evidence  that  the  disease  is  due  to  the  circulation  of  some  poisonous  sub- 
stance  in  the  blood  which  gives  rise  to  thrombosis  in  many  of  the  smaller 
vessels,  with  consequent  degenerative  and  necrotic  changes  imthe  various 
organs.  But,  at  the  same  time,  we  are  absolutely  ignorant  concerning  the 
natureTof  the  offending  substance,  and  besides,  the  experimental  evidence 
thus  far  adduced  in  favour  of  such  an  aetiological  factor  is  not  convincing. 

Schmorl  at  one  time  believed  that  the  thrombotic  processes  were  made 
possible  by  the  action  of  a  fibrin  ferment  set  free  from  placental  cells  which 
had  escaped  into  the  maternal  circulation.  His  later  investigations,  how- 
ever, tended  to  invalidate  this  assumption. 

Bulius  and  Falk  noted  a  marked  proliferation  of  the  syncytium  in  the 
placenta,  and  this  they  considered  characteristic  of  the  disease.  Their 
results,  however,  have  not  been  verified  by  other  investigators,  nor  have  I 
been  able  to  confirm  them  in  the  eclamptic  placentae  which  I  have  ex- 
amined. 

Several  observers  believe  that  they  have  demonstrated  the  presence 
of  other  substances  in  the  blood  serum  or  urine  which  might  explain  th'e 
production  of  eclampsia.  Thus,  Massen  described  an  increase  in  leuco- 
maines,  and  Kollmann  thought  he  demonstrated  an  unusual  amount  of 
globulin  in  the  blood  serum.  Their  researches  have  not  yet  been  confirmed, 
and  their  conclusions  must  therefore  be  accepted  with  reserve. 

During  the  past  few  years  a  number  of  authors,  particularly  Fehling 
and  Dienst,  have  advanced  the  theory  that  the  disease  may  be  due  to  intox- 
ication with  products  of  the  foetal  metabolism,  the  maternal  organism  being 
sometimes  unable  to  accommodate  itself  to  the  increased  work  necessary 
for  their  elimination  as  well  as  that  of  its  own  excretory  products.  They 
argue,  therefore,  that  under  such  circumstances  certain  poisonous  mate- 


ECLAMPSIA  70S 

rials;  could  accumulate  in  the  system  and  eventually  give  rise  to  organic 
lesions  in  the  mother. 

This  view  receives  a  certain  amount  of  support  from  clinical  experience, 
since,  as  is  well  known,  the  convulsions  usually  cease  soon  after  delivery; 
while  in  rare  cases  the  death  of  the  foetus  during  pregnancy  is  immediately 
followed  by  recovery.  Moreover,  Baron  and  Castaigne  have  lately  demon- 
strated that  the  transmission  to  the  mother  of  substances  injected  into  the 
foetus  ceases  almost  immediately  after  its  death. 

The  advocates  of  the  foetal  origin  of  eclampsia  also  adduce  as  an  argu- 
ment the  fact  that  convulsions  sometimes  appear  in  the  child  shortly  after  its 
birth.  Cases  of  this  character  have  been  reported  by  TTilke,  Woyer,  Schmid, 
Dienst.  and  others,  and  in  several  instances  characteristic  lesions  were  ob- 
served in  the  organs  of  the  foetus.  Furthermore,  lesions  identical  with  those 
in  the  liver  and  kidneys  of  the  mothers  have  been  observed  in  the  corre- 
sponding organs  of  children  which  were  born  dead  or  died  soon  after  deliv- 
ery. Such  observations  have  been  made  by  Schmorl,  Chamberlent,  Bar  and 
Guyeisse,  Knapp,  Dienst,  and  myself,  and  are  considered  critically  in 
Dienst's  monograph. 

The  observations  of  Kronig  and  Flith  upon  the  osmotic  pressure  of  the 
foetal  and  maternal  blood  show  that  there  is  no  fundamental  objection  to 
the  acceptance  of  such  a  theory;  but  at  the  same  time,  I  do  not  believe  that 
the  demonstration  of  lesions  in  the  organs  of  the  foetus  necessarily  affords 
evidence  of  its  correctness.  To  my  mind  such  findings  simply  prove  that 
they  are  the  result  of  the  circulation  of  some  substance  in  J-be_b1ood  which 
leads  to  the  formation  of  thrombi,  with  subsequent  necrosis,  although  as 
yet  the  evidence  is  insufficient  to  indicate  whether  it  is  transmitted  through 
the  placenta  from  the  foetus  to  the  mother,  or  in  the  opposite  direction. 

In  summing  up  the  aetiology  of  eclampsia,  it  appears  that  the  evidence 
thus  far  adduced  in  support  of  the  auto-intoxication  theory,  though  not 
conclusive,  is  sufficiently  suggestive  to  warrant  its  tentative  acceptance,  at 
least  until  some  better  explanation  is  forthcoming.  I  believe  that  it  is 
probable  that  further  studies  of  the  metabolism  in  normal  pregnancy  as 
well  as  in  eclampsia  will  eventually  afford  us  definite  information  concern- 
ing its  causation. 

An  interesting  contribution  to  the  subject  has  been  made  by  Helouin, 
who  studied  what  he  calls  the  "  rapport  azoturicme  " — the  relation  between 
the  total  nitrogen  of  the  urine  and  the  amount  eliminated  as  urea — in  the 
albuminuria  of  pregnancy  and  eclampsia.  He  found  that  in  normal  urine 
80  to  90  per  cent  of  the  total  nitrogen  was  eliminated  in  the  form  of  urea, 
but  only  a  much  smaller  proportion  in  diseased  conditions. 

Diagnosis. — The  diagnosis  of  eclampsia  usually  offers  no  difficulty,  espe- 
cially when  the  patient  has  been  under  observation  during  the  later  months 
of  pregnancy.  When  the  woman  is  first  seen  in  a  seizure  it  becomes  neces- 
sary to  differentiate  the  condition  from  uraemia,  epilepsy,  and  a  hysterical 
csmsxdsiaiL 

Prognosis. — The  prognosis  is  always  serious,  eclampsia  beinsr  regarded  as 
one  of  the  most  dangerous  conditions  with  which  the  obstetrician  has  to 
deal.  The  maternal  mortality  varies  from  20  to  25  per  cent,  and  that  of 
'      46 


706  OBSTETRICS 

the  foetus  from  33  to_50  per  cent,  although  Porak  and  Stroganoff  report 
series  of  "17  and  113  cases  with  a  maternal  mortality  of  6.38  and  5.31  per 
cent  respectively.     Such  favourable  results,  however,  are  very  exceptional. 

As  a  rule,  the  prognosis  is  more  gloomy  when  the  seizures  come  on  be- 
fore  or  during  parturition,  whereas  post-partnm  eclampsia  is  considered 
less  dangerous.  Eecent  statistics,  however,  indicate  that  the  last  variety 
is  more  serious  than  is  generally  believed,  Green,  Zweifel,  and  Olshausen 
having  lost  6.6,  9.5,  and  25  per  cent  of  their  cases  respectively. 

There  is  considerable  discrepancy  of  opinion  concerning  the  relative 
prognosis  in  primiparous  an^multujaarous  women.  Thus,  Veit  in  902 
cases  gives  a  corrected  "mortality  of  14.|  per  cent  for  the  former  and  19.5 
per  cent  for  the  latter,  and  Goldberg  states  the  disorder  is  twice  as  danger- 
ous in  the  latter.  Olshausen,  on  the  other  hand,  believes  that  there  is  no 
difference  in  the  two  groups,  and  Zweifel  states  that  the  mortality  among 
his  patients  was  3  times  greater  in  primiparse  (16.6  to  5.5  per  cent).  In  all 
probability  the  prognosis  really  depends  much  more  upon  the  severity  of  the 
attack  than  upon  the  number  of  children  that  the  woman  has  borne. 

In  individual  cases  it  is  often  extremely  difficult  to  predict  the  course 
of  the  disease,  some  patients  dying  in  the  first  seizure  while  others  recover 
after  as  many  as  30.  Winckel  states  that  he  has  never  observed  recovery 
after  more  than  18  convulsions,  but  my  own  experience  does  not  bear  out 
this  assertion.  At  the  same  time,  there  is  no  doubt  that,  other  things 
being  equal,  the  prognosis  becomes  more  and  more  serious  with  each  con- 
vulsion, although  their  absolute  number  is  not  of  so  much  moment  as  the 
i  rapidity  with  which  they  follow  one  another  and  the  duration  of  the  coma 
I  after  each  attack. 

Valuable  prognostic  data  are  also  afforded  by  the  condition  of  the  pulse 
and  temperature.  When  the  former  remains  full  and  firm  between  the 
attacks,  the  outlook  is  usually  good;  whereas  a  weak,  rapid,  and  thready 
pulse,  usually  indicates  a  fatal  issue,  particularly  if  the  temperature  is  high. 
Apoplexy,  paralysis,  and  oedema  of  the  lungs  are  most  serious  complica- 
tions and  usually  end  in  death. 

If  the  eclampsia  comes  on  during  pregnancy  the  prognosis  is  very 
favourably  affected  by  the  death  of  the  foetus,  the  convulsions  usually  ceas- 
ing soon  afterward. 

Treatment. — (a)  Prophylactic. — The  prophylactic  treatment  is  most  im- 
portant, and  is  identical  with^hat  recommended  for  the  toxaemia  of  preg- 
nancy (p.  455).  Indeed,  the  chief  aim  in  treating  the  latter  condition  is 
to  prevent  the  possible  outbreak  of  eclampsia.  Hence  the  necessity  of 
regular  and  frequent  examinations  of  the  urine,  and  the  immediate  institu- 
tion of  appropriate  treatment  and  diet  as  soon  as  any  abnormality  is  de- 
tected or  symptoms  appear  which  indicate  that  the  eliminative  pro- 
cesses are  at  fault.  By  the  employment  of  these  precautionary  measures,  and 
by  promptly  inducing  premature  labour  in  those  cases  which  do  not  improve 
or  which  become  progressively  worse  under  treatment,  the  frequency  of 
eclampsia  will  be  greatly  diminished  and  many  valuable  lives  saved.  At 
present,  however,  despite  all  we  can  do,  cases  of  eclampsia  will  still  occur, 
and  sometimes  even  in  patients  who  apparently  have  responded  most  satis- 


ECLAMPSIA  707 

factorily  to  prophylactic  treatment.  Thus,  I  could  cite  several  instances 
in  which,  under  appropriate  measures,  the  subjective  symptoms  disap- 
peared, the  urine  and  urea  increased  in  quantity  and  the  albumin  de- 
creased, and  yet,  just  as  I  was  congratulating  myself  upon  a  most  satisfac- 
tory result,  a  convulsion  occurred.  Moreover,  one  of  my  patients  who  was 
apparently  perfectly  well,  and  whose  urine  had  shown  no  abnormality  the 
day  before  labour,  had  an  eclamptic  seizure  just  after  delivery. 

Such  experiences  have  convinced  me  that  prophylactic  treatment,  while 
productive  of  untold  good,  is  not  invariably  successful  or  always  applicable, 
nor  can  I  agree  with  Davis  and  Edgar  that  eclampsia  is  always  a  prevent- 
able affection.  Such  a  satisfactory  condition  of  affairs  can  hardly  obtain 
until  its  aetiology  is  perfectly  understood,  and  we  are  in  possession  of  more 
accurate  and  reliable  methods  of  foretelling  the  outcome  in  cases  of  tox- 
aemia of  pregnancy. 

Experience  goes  to  show  that  the  cases  accompanied  by  oedema  are  more 
readily  amenable  to  treatment  and  less  likely  to  eventuate  in  eclampsia 
than  those  in  which  it  is  absent.  This  point  was  emphasized  many  years 
ago  by  Stoltz. 

(&)  Curative. — In  the  presence  of  actual  eclampsia,  chloroform  should 
be  administered,  during  the  convulsive  attacks  in  the  hope  of  cutting  them 
short,  after  which  comparatively  large  doses  of  morphine  should  be  given 
hypodermically,  beginning  with  a  quarter  of  a  grain  and  repeating  it,  if 
necessary,  until  3  doses  have  been  administered. 

Diuresis  should  be  stimulated  as  much  as  possible,  especially  by  the  ap- 
plication of  hotjpacks.  The  bowels  should  be  moved  by  a  strong  cathartic, 
preferably  1  drop  of  croton-oil  ina  dram  of  olive-oil,  placed  on  the  back 
of  the  tongue  if  the  patient  is  unconscious.  At  the  same  time  a  thick 
cork  or  folded  towel  placed  between  the  teeth  will  prevent  the  patient  from 
biting  her  tongue  during  the  attacks.  Food  or  medicine  should  not  be  ad- 
ministered by  the  mouth  as  long  as  the  patient  is  unconscious,  as  in  many 
instances  particles  find  their  way  into  the  air-passages  instead  of  being 
swallowed,  and  later  give  rise  to  an  inspiration  pneumonia. 

When  convulsions  have  once  occurred,  the  pregnancy  or  labour,  as  the 
case  may  be,  should  be  terminated  as  soon  as  is  consistent  with  the  safety 
of  the  patient.  There  is,  however,  considerable  divergence  of  opinion  upon 
this  point.  J.  Veit  and  Charpentier  advocate  the  administration  of  mor- 
phine in  large  doses,  but  not  interfering  until  the  cervix  is  completely 
dilated,  and  then  emplo}dng  forceps  or  version.  Diihrssen,  Zweif el,  and  most 
American  authorities,  on  the  other  hand,  advocate  emptying  the  uterus  at 
an  earlier  period,  provided  it  can  be  done  without  serious  injury  to  the 
mother. 

The  question  as  to  the  advisability  of  early  operative  interference,  in 
my  opinion,  can  only  be  decided  by  determining  the  proportion  of  cases 
in  which  the  convulsions  cease  after  the  birth  of  the  child.  Statistics 
bearing  upon  this  point  have  been  adduced  by  Diihrssen,  Olshausen,  and 
Zweifel,  who  noted  a  cessation  of  the  seizures  either  immediately  or  soon 
after  delivery  in  93.75  per  cent,  85  per  cent,  and  66  per  cent  of  their  cases 
respectively.    Zweifel  reports  a  mortality  of  28.5  per  cent  under  expectant, 


708  OBSTETRICS 

and  11.25  per  cent  under  active  treatment.    Judging  from  these  figures  it 
C  J  would  appear  that  prompt  delivery  is  indicated  whenever  it  can  be  accom- 
v  plished  in  a  conservative  manner. 

In  the  majority  of  cases,  even  in  ante-partum  eclampsia,  speedy  delivery 
is  facilitated  by  the  fact  that  uterine  contractions  come  on  or  increase Jri 
force  soon  after  the  onset  of  the  disease,  and  labour  usually  pursues  a  more 
rapid  course  than  usual.  Thus,  in  many  instances,  after  the  first  few  con- 
vulsions the  cervical  canal  is  found  to  be  already  obliterated,  the  only  re- 
sistance to  the  birth  of  the  child  being  offered  by  the  external  os.  When 
this  is  the  case,  delivery  is  readily  accomplished  by  dilating  the  cervix  by 
Harris's  method,  as  described  in  Chapter  XIX.  In  this  way,  provided  that 
the  external  os  will  admit  the  tips  of  two  fingers,  complete  dilatation  can 
be  readily  and  harmlessly  accomplished  in  a  surprisingly  short  space  of 
time,  often  within  eight  or  ten  minutes.  The  child  should  then  be  deliv- 
ered  by  forceps  if  the  head  is  low  down  in  the  pelvis,  or  by  version  if  it  is_ 
only  slightly  engaged  or  movable  above  the  pelvic  brim. 

If,  however,  labour  has  not  set  in  and  the  cervical  canal  is  intact,  the 
question  of  rapid  delivery  becomes  more  complicated,  and  it  becomes  neces- 
sary to  determine  whether  it  is  more  advisable  to  adopt  expectant  treat- 
ment or  to  attempt  to  hasten  delivery.     In  such  cases,  Diihrssen  advocates 
deep  multiple  incisions  of  the  cervix  followed  by  rapid  extraction.     I  am 
not  convinced  as  to  the  propriety  of  such  a  procedure,  but  prefer  to  bring 
about  with  steel  dilators  a  degree  of  dilatation  sufficient  to  permit  the  intro- 
duction of  a  Champetier  de  Kibes's  balloon,  which  is  then  inflated  with  steril- 
ized salt  solution  and  allowed  to  overcome  the  resistance  of  the  internal  os, 
its  action  being  hastened,  if  desired,  by  .gentle  traction  upon  the  tube  at- 
tached to  the  apparatus.    In  most  cases  the  cervical  canal  yields  promptly  to 
the  dilating  bag,  after  which  dilatation  can  be  completed  by  Harris's  meth- 
od, or,  if  necessary,  by  multiple  incisions.    I  do  not  advocate  manual  dilata- 
tion when  the  cervicai  canal  is  intact,  as  the  operation  is  extremely  tedious, 
sometimes  requiring  several  hours,  and  nearly  always  results  in  deep  tears 
of  the  cervix,  which  sometimes  extend  through  the  lower  uterine  segment. 
/        In  the  rare  instances  in  primiparous  women  in  whom  the  external  os 
\and  cervical  canal  are  very  resistant  and  almost  cartilaginous  in  consistence, 
/so  that  they  cannot  be  dilated  sufficiently  to  permit  even  the  introduction  of 
I  the  bag,  prompt  delivery  can  be  effected  only  by  means  of  Dtihrssen's  deep 
J  incisions  or  by  Cesarean  section.    In  such  cases,  unless  the  obstetrician  is  a 
J  competent  operator,  I  believe  he  will  subserve  the  interests  of  the  patient 
better  by  not  attempting  delivery,  and  placing  his  reliance  upon  medicinal 
treatment.    On  the  other  hand,  if  the  case  appears  desperate,  the  child  being 
viable  and  still  alive,  and  the  patient  is  in  a  well-conducted  hospital,  the 
advantages  of  Cassarean  section,  as  advocated  by  Halbertsma  in  1889,  should 
be  carefully  considered. 

Certainly,  in  the  class  of  cases  under  discussion,  it  will  prove  a  more  con- 
servative procedure  than  forcible  and  brutal  dilatation  of  a  rigid  cervix,  but 
at  the  same  time  it  should  be  resorted  to  only  as  a  last  expedient  in  a  few 
very  exceptional  cases.  Kettlitz,  in  1897,  collected  27  cases  with  a  mor- 
tality of  47.3  per  cent,  while  Hillmann,  in  1900,  reported  a  mortality  of 


ECLAMPSIA  709 

52.5  per  cent  in  10  cases.  Tt  is  true  that  these  figures  do  not  appear  very 
encouraging,  bul  it  must  be  remembered  that  all  the  patients  were  in  a  des- 
perate  condition,  and  were  operated  upon  as  a  last  resort,  so  thai  in  all 
probability  even  a  greater  number  would  have  died  under  expectant  treat- 
ment. Olshausen  has  performed  the  operation  3  times  in  his  last  250  cases 
of  eclampsia,  saving  2  of  the  mothers  and  all  of  the  children. 

After  the  birth  of  the  child  no  attempt  should  be  made  to  hasten  theX) 
third  stage  of  labour,  as  a  moderate  loss  of  blood  should  be  encouraged  f\ 
rather  than  cheeked. 

Alter  the  delivery  of  the  placenta  one  should  continue  to  stimulate  diu- 
resis and  diaphoresis,  especially  by  means  of  hot  packs,  and  a  second  dose 
of  croton-oil  should  be  administered  if  the  first  has  been  ineffectual.  Diu- 
resis  is  notably  favoured  by  the  subcutaneous  injection  of  lar^e_ajnimnj;s 
of  salt  solution.  Thompson  has  lately  demonstrated  this  fact  for  dogs,  and 
showed  that  in  some  cases  the  flow  of  urine  was  increased  by  at  least  300 
per  cent. 

If  the  patient  does  not  show  marked  signs  of  improvement  shortly  after 
delivery,  from  300  to  500  cubic  centimetres_of  blood  should  be  withdrawn. 
If  beneficial  results  follow,  the  procedure  ma}T  be  repeated  if  necessary.  As 
the  average  woman  possesses  from  8^  to  9  pounds  of  blood,  500  cubic  centi- 
metres would  represent  from  £  to  -5-  of  its  total  bulk.  Accordingly,  if  that 
amount  of  blood  is  drawn  off  and  replaced  by  an  infusion  of  an  equal  quan- 
tity of  salt  solution,  the  remainder  of  the  blood  is  so  diluted  that,  for  prac- 
tical purposes,  ^  or  \  of  the  total  poison  has  been  removed,  and  this  aid  is 
often  sufficient  to  tide  the  patient  over  sufficiently  long  to  allow  Xature  to 
reassert  herself. 

It  is  generally  stated  that  bleeding  is  indicated  only  when  the  pulse  is 
full  and  bounding.     Personally.  I  have  bled  with  most  excellent  results 
a  number  of  patients  whose  pulse  was  thin  and  weak.     This  experience 
would  certainly  seem  to  show  that  venesection  is  indicated  in  all  cases  in  . 
which  delivery  of  the  child  is  not  followed  by  a  cessation  of  the  convulsions,  )  /  ^ 
no  matter  what  the  condition  of  the  pulse. 

Pilocarpine  should  never  be  used,  on  account  of  its  tendency  to  produce 
oedema  of  theTungs,  nor  have  I  any  experience  with  veratrum  viride,  which 
is  so  highly  praised  by  many  American  writers. 

In  view  of  the  marked  liability  of  eclamptic  women  to  infection,  all   ) 
operative  procedures  must  be  conducted  in  the  most  rigidly  aseptic  manner,    j 
particular  care  being  taken  to  avoid  the  contamination  of  the  vagina  and 
the  hands  of  the  operator  by  faecal  material. 

LITERATURE 

Bar.     Est-il  demontre  que  l'eclampsie  est  une  maladie  mierobienne?     L'Obstetrique.  iii, 

1898.  481-505. 
Bar  et  Gcyeisse.     Lesions  du  foie  et  des  reins  ehez  les  eelamptiques  et  les  foetus  issus 

des  ferames  eelamptiques.     L'Obstetrique.  1897.  ii.  263. 
Barox  et  Castaigxe.     Contribution  a  l'etude  de  la  pathogenie  de  l'eclampsie  puerperale. 

etc.     Archives  de  med.  exp.  et  d'anat.  path..  1898.  x.  693-711. 
Blaxc.     Pathogenie  de  l'eclampsie.     Archives  de  Tocol.,  1890,  xvii.  T4T-T54. 


1  '    > 


710  OBSTETRICS 

Blumreich   und   Zuntz.     Exp.  und  kritische  Beitrage  zur  Pathogenese  der  Eklampsie. 

Archiv  f.  Gyn.,  1902,  lxv,  736-785. 
Bouchard.     Le9ons  sur  l'auto-intoxication.     Paris,  1887. 
Bouffe  de  Saint  Blaise.     Lesions  anat.  que  Ton  trouve  dans  l'eclampsie.     These  de 

Paris,  1891. 
Foie  et  eclampsie  puerperale.     Annales  de  Gyn.  et  d'Obst.,  1891,  xxxv,  48. 
Les  auto-intoxications  gravidiques.     Annales  de  Gyn.  et  d'Obst.,  1898,  1,  342-373. 
Quelques  cas  d'acces  eclamptiques  sans  albuminurie.     Annales  de  Gyn.  et  d'Obst.,  1900, 

liv,  76-77. 
Bulius.     Gutartige  Wucherungen  des  Syncytiums.     Centralbl.  f.  Gyn.,  1897,  693-695. 
Cassamayor.     Contribution  a  l'etude  de  l'eclampsie  puerperale  d'apres  une  statistique  de 

la  Clinique  de  1872-1892.     These  de  Paris,  1892. 
Chamberlent.     Toxicite  de  serum  maternal  et  foetal  dans  un  cas  d'eclampsie  puerperale. 

Archives  cliniques  de  Bordeaux,  1894,  271-284. 
Recherches  exp.  et  anat.  path,  sur  les  causes  de  la  rnort  du  foetus  dans  l'eclampsie  puer- 
perale.    Nouv.  Arch.  d'Obst.  et  de  Gyn.,  1895,  175. 
Chamberlent  et  Demont.     Recherches  exp.  sur  la  toxicite  de  Purine  dans.les  derniers 

mois  de  la  grossesse.     Comptes  rendus  Soc.  de  Biol.,  1892,  iv,  27-35. 
Charpentier.     Eclampsie  sans  albuminurie.     Traite  pratique  des  accouchements.     Paris, 

1883,  i,  699. 
Traitement  de  l'eclampsie.     Annales  de  Gyn.,  1896,  xliv,  488. 
Combemale  et  Bue.    Faits  a  l'appui  de  la  nature  microbienne  de  l'eclampsie  puerperale. 

Comptes  rendus  Soc.  de  Biol.,  1892,  iv,  244-245. 
Davis.     The  Prophylaxis  and  Treatment  of  Eclampsia.     Therapeutic  Gazette,  July  15, 

1895 ;  also  Trans.  Amer.  Gyn.  Soc,  1895. 
Eclampsia,  Ante-  and  Post-partum.     Amer.  Jour.  Obst.,  1898,  xxxvii,  467-480. 
Dblore  et  Rodet.     Memoire  sur  l'etiologie  bacterienne  de  l'eclampsie.     Resume  dans 

l'Arch.  de  Tocologie,  1884,  ii,  921. 
Dienst.     Kritische  Studien  uber  die  Pathogenese  der  Eklampsie,  etc.     Archiv  f.  Gyn., 

1902,  lxv,  369-464. 
Doderlein.     Zur  Prage  der  "  Eklampsie."     Centralbl.  f.  Gyn.,  1893,  1. 
DiiHRSSEN.     Ueber  Eklampsie.     Theil  II,  Archiv  f.  Gyn.,  1893,  xliii,  49-161. 
Edgar.    The  Treatment  of  Puerperal  Eclampsia.     N.  Y.  Med.  Record,  December  26,  1896, 

and  January  2,  1897. 
Elliot.     Obstetrical  Clinic,  New  York,  1873. 

Palk.     Partielle  hydropische  Degeneration  der  Placenta  bei  einer  Eklamptischen.     Cen- 
tralbl. f.  Gyn.,  1897,  1073-1078. 
Favre.     Ueber  eine  Methode  der  Nephrectomie  und  iiber  Schwangerschaftsniere  und 

Eklampsie  auf  bakterial-physikalischen  Basis.     Virchow's  Archiv,  1892,  cxxix,  40-61. 
Fehling.     Die  Pathogenese  und  Behandlung  der  Eklampsie  im    Lichte  der  heutigen 

Anschauungen.     Volkmann's  Sammlung  klin.  Vortrage,  N.  F.,  1899,  Nr.  248. 
Begriff  und  Pathogenese  der  Eklampsie.    Verh.  cler  deutschen  Gesell.  f.  Gyn.,  1901, 

239-261. 
Forchheimer  and  Stewart.     On  the  Toxicity  of  the  Urine.     Amer.  Jour.  Med.  Sciences, 

September,  1899,  297-303. 
Gerdes.     Zur  Aetiologie  der  Puerperal-eklampsie.     Centralbl.  f.  Gyn.,  1892,  379-384. 
Goldberg.     Beitrag  zur  Eklampsie  auf  Grund  von  81  Fallen.     Archiv  f.  Gyn.,  1891,  xii, 

295-329 ;  and  1892,  xiii,  87-102. 
Green.     Puerperal  Eclampsia.     Trans.  Amer.  Gyn.  Soc,  1893,  xviii,  141-174. 
Guenard.     Etude  de  la  permeabilite  renale  chez  les  eclamptiques  par  le  procede  du  bleu 

de  methylene.     These  de  Paris,  1898. 
Haegler.     Zur  Frage  "  Eklampsiebacillus"  Gerdes.     Centralbl.  f.  Gyn.,  1892,  996-998. 
Halbertsma.     Ueber  die  Aetiologie  der  Eklampsia  puerperalis.     Volkmann's  Sammlung 

klin.  Vortrage,  1884,  Nr.  212. 


ECLAMPSIA  711 

Balbertsma.     Eklampsia  gravidarum.     Eine  neue  Indikationsstellung  fur  die  Sectio 

Caesarea.     Ref.  Centralbl.  f.  Gyn.,  L889,  901. 
Helouin.    Contribution  a  l'etude  du  diagnostic  de  I'hepato-toxheinie  gravidique.    These 

de  Paris,  1899. 
Herff.    Zur  Theorie  der  Eklampsie.     Centralbl.  I  Gyn.,  1892,  230-233. 
Hekkgott.    Consideration  sur  la  pathogeniede  l'eclampsie  puerperale.     Annales  de  Gyn., 

1893.  xxxix,  1-8 ;  109-120. 
Iln. L.Mann.      Kin  Eall  von  Sectio  ('acsarca.  aus<;vl'ulii'1   wegen    Eklampsie.     Monatsschr.  f. 

Geb.  un.l  Gyn.,  L899,  x.  193-207. 
Eughes  and  Carter.    A  clinical  Experimental  Study  of  Uraemia.    Amer.  Jour.  3Ied. 

Sciences,  1894,  cviii.  177-193;  265-295. 
[ngerslev.     Beitrag  zur  Albuminuric  wahrend  der  Schwangerschaft,  der  Geburt  und  der 

Eklampsie.     Zeitschr.  f.  Geb.  u.  Gyn.,  1881,  vi,  171-212. 
JOrgens.     Fettemboli  und  Metastase  von  Leberzellen  bei  Eklampsie,  etc.     Berliner  klin. 

Wochenschr.,  1880,  519. 
Kkttlitz.     Ueber  Kaiserschnitt  wegen  Eklampsie.     D.  I.,  Halle,  1897. 
Klebs.     Multipel  Leberzellen-tlirombose.     Ziegler's  Beitrage,  1888,  iii,  1-30. 
Knai'p.     Klinische  Beobuchtungen  iiber  Eklampsie.     Berlin.  1896. 

Ueber  puerperale  Eklampsie  und  deren  Behandlung.     Berlin,  1900. 
Kollmann.     Zur  Aetiologie  und  Therapie  der  Eklampsie.     Centralbl.  f.  Gyn.,  1897,  341- 

346. 
Kronig  und  Futii.    Experimentelle  Untersuchungen  iiber  Eklampsie.    Verh.  d.  deutschen 

Gesell.  f.  Gyn.,  1901,  313-332. 
Lafox.     Contribution  a  l'etude  de  quelques  formes  anormales  d'eclampsie.     These  de 

Paris,  1899. 
Lever.     Cases  of  Puerperal  Convulsions,  with  Remarks.     Guy's  Hospital  Reports,  1843. 
Levixowitch.     Bakteriologische  Untersuchung  des  Blutes  bei  Eklampsie.     (Vorlaufige 

Mittheilung.)     Centralbl.  f.  Gyn..  1899,  1385-1387. 
Lohlelx.     Zur  Haufigkeit,  Prognose  und  Therapie  der  Eklampsie.     Verh.  der  deutschen 

Ges.  f.  Gyn.,  1891,  177-179. 
Lubarsch.     Die  Puerperal-eklampsie.     Ergebnisse  der  allg.  Path,  und  path.  Anat.,  1896, 

i,  113-134. 
Ludwig  und  Savor.     Experimentelle  Studien  zur  Pathogenese  der  Eklampsie.     Monats- 

schr.  f.  Geb.  u.  Gyn.,  1895,  447-473. 
Massex.     Zwischenprodukte  des  Stoffwechsels  als  Ursache  der  Eklampsie.    Ref.  Cen- 
tralbl. f.  Gyn.,  1896.  1208. 
Matgrier.     Quoted  by  Lafon. 
Newell.     Eclampsia  in  the  Boston  City  Hospital  for  the  Past  Fifteen  Years.    Boston  Med. 

and  Surg.  Jour.,  November  9,  1899. 
Olshausex.     Ueber  Eklampsie.     Volkmann's   Sammlung  klin.  Vortrage,  N.  F.,  1891, 

Xr.  39. 
Sectio  Caesarea  wegen  Eklampsie.     Centralbl.  f.  Gyn.,  1900,  63. 
Pels  Letjsden.      Beitrage   zur  path.   Anatomie   der   Puerperal-eklampsie.      Yirchow's 

Archiv,  1895,  cxlii,  1-45. 
Pilliet  et  Letiexxe.     Lesions  du  foie  dans  l'eclampsie  avec  ictere.     Xouv.  Arch.  d'Obst. 

et  de  Gyn.,  1889,  iv,  312-367. 
Porak.     Traitement  de  l'eclampsie  puerperale.     Annales  de  Gyn.  et   d'Obst.,  1900,  liv, 

79-96. 
Pritz.     Ueber  des  anat.  Verhalten  der  Nieren  bei  der  Puerperal-eklampsie.     Zeitschr.  f. 

Geb.  u.  Gyn.,  xxiii,  1892,  1-52. 
Ueber  Eklampsie.     Yereins-Beilage  der  deutsch.  med.  Wochenschr.,  1897,  194. 
Rayer.     Traite  des  maladies  des  reins.     Paris.  1839. 
Riviere.     Pathogenie  et  traitement  de  l'eclampsie.     Paris,  1889. 
Rosexsteix.     Ueber  Eklampsie.     Monatsschr.  f.  Geburtsk.  u.  Gyn.,  1864,  xxiii,  413-430. 


712  OBSTETRICS 

Schmid.     Eklampsie  bei  Mutter  u.  Kind.     Centralbl.  f.  Gyn.,  1897,  821-827. 
Schmorl.     Path.  anat.  Untersuchungen  iiber  Puerperal-eklampsie.     Leipzig,  1893. 

Zur  Lehre  Ton  der  Eklampsie.     Archiv  f.  Gyn.,  1902,  lxv,  504-529. 
Schroeder.     Quoted  by  Ingerslev. 
Schusiacher.     Exper.  Beitrage  zur  Eklarnpsie-frage.     Hegar's  Beitrage  zur  Geb.  u.  Gyn., 

1901,  v,  257-309. 
Sourel.     Contribution  a  l'etude  des  acces  eclamptiques  et  plus  particuliere  de  leur  pa- 
thogenic    Paris,  1894. 
Spiegelberg.     Ein  Beitrag  zur  Lehre  von  der  Eklampsie.     Ammonia  im  Blute.     Archiv 

f.  Gyn.,  1870,  i,  383-391. 
Stewart.     Toxicity  of  the  Urine  in  Pregnancy.     Amer.  Jour.  Obst.,  1901,  xliv,  506-575. 
Stroganoff.     "Leber  die  Behandlung  der   Eklampsie.     Centralbl.  f.  Gyn.,   1901,  1309- 

1312. 
Tarnier  et  Chamberlent.    Note  relative  a  la  recherches  de  la  toxicite  du  serum  sanguin 

dans  deux  cas  d'eclampsie.     Comptes  rendus  de  la  Soc.  de  Biol.,  1892,  iv,  179-182. 
Thompson.     The  Influence  of  Sodium  Chloride  on  the  Secretion  of  Urine.    British  Med. 

Jour.,  April  1,  1899,  793. 
Van  der  Bergh.     Leber  die  Giftigkeit  des  Harns.     Zeitschr.  f.  klin.  Medizin,  1898,  xxxv,. 

52-79. 
Van  der  Velde.     Eklampsia  puerperalis  tardiforma.     Ref.   Frommel's  Jahresberieht, 

1897,  752. 
Veit,  J.     Ueber  die  Behandlung  der  Eklampsie.     Ruge's  Festschrift,  1896,  101-120. 
Volhard.     Exp.  und  kritische  Studien  zur  Pathogenese  der  Eklampsie.     Monatsschr.  f. 

Geb.  u.  Gyn.,  1897,  411-437. 
Wilke.     Ein  Fall  von  Encephalitis  des  Kindes  bei  Eklampsie  der  Mutter.     Centralbl.  f. 

Gyn.,  1893,  385-392. 
Winckel.     Lehrbuch  der  Geburtshiilfe,  1893,  II.  Aufl.,  536-547. 
Winckler.     Beitrag  zur  Lehre  von  der  Eklampsie.     Virchow's  Archiv,  1898,  cliv,  187- 

233. 
Woyer.     Ein  Fall  von  Eklampsie  bei  Mutter  und  Kind.     Centralbl.  f.  Gyn.,  1895,  329- 

334. 
Zweifel.    Zur  Behandlung  der  Eklampsie,  Bericht  iiber  129  hier  beobachtete  Falle. 

Centralbl.  f.  Gyn.,  1895,  1201-1218;  1238-1256;  1265-1277. 


CHAPTER    XLI 

HEMORRHAGE 

PREMATURE  SEPARATION  OF  THE  NORMALLY  IM- 
PLANTED PLACENTA— PLACENTA  PREVIA  -  POST- 
PARTUM   HEMORRHAGE— INVERSION  OF  THE   UTERUS 

A  profuse  haemorrhage  occurring  prior  to  or  shortly  after  the  birth  of 
the  child  is  always  dangerous  and  not  infrequently  a  fatal  complication. 
Practically  all  classes  of  ante-partum  hemorrhage,  with  the  exception  of 
those  originating  from  lacerations  of  the  genital  canal,  are  clue  to  a  partial 
or  complete  separation  of  the  placenta  from  its  attachment  to  the  uterine 
wall.  This  accident  is  an  inevitable  accompaniment  of  labour  when  the 
placenta  is  implanted  in  the  neighbourhood  of  the  internal  os— placenta 
prsevia — but  occasionally  occurs  when  the  organ  occupies  its  normal  site  in 
the  upper  portion  of  the  uterus. 

Premature  Separation  of  the  Normally  Implanted  Placenta. — From  the 
time  of  Hippocrates  it  had  been  customary  to  ascribe  all  cases  of  ante- 
partum haemorrhage  to  this  accident,  but  with  the  recognition  of  the  nature 
of  placenta  praevia  and  the  knowledge  that  its  separation  is  unavoidably 
associated  with  haemorrhage,  the  earlier  view  was  abandoned  and  the  former 
accident  came  to  be  regarded  as  of  rare  incidence. 

Goodell,  in  1869,  collected  106  instances  from  the  literature,  while 
Holmes,  in  1901,  was  able  to  find  200  additional  cases.  The  latter  writer, 
however,  believes  that  these  figures  give  a  very  inadequate  idea  of  the 
frequency  of  the  accident,  and  he  himself  considers  that  it  occurs  about 
once  in  every  500  labours.  His  contention  is  confirmed  by  Lyle's  statis- 
tics, which  show  that  40  cases  were  observed  in  the  Rotunda  Hospital  of 
Dublin  during  the  ten  years  ending  with  1899.  Inasmuch  as  I  have  met 
with  only  3  instances,  my  own  experience  leads  me  to  believe  that  the  con- 
dition is  extremely  rare. 

JEtiology. — Unfortunately,  the  primary  cause  of  the  premature  separa- 
tion of  the  placenta  is  imperfectly  understood,  although  a  number  of  theo- 
ries have  been  advanced  concerning  it.  In  67  of  Holmes's  cases  there  was 
a  history  of  a  preceding  traumatism  which,  according  to  Coe,  is  the  most 
common  aetiological  factor.  On  the  other  hand,  most  German  authorities 
attribute  the  accident  to  inflammatory  changes  in  the  decidua,  which  were 
present  in  every  one  of  the  8  cases  examined  by  Weiss,  although  in  2  of 
them  the  predominant  lesion  was  a  suppurative  metritis. 

713 


14 


OBSTETRICS 


Winter  believes  that  a  close  relationship  exists  between  nephritis  and 
premature  separation  of  the  placenta,  and  many  authors  have  subscribed 
to  this  opinion.  Weiss,  on  the  other  hand,  was.  able  to  demonstrate  albu- 
minuria in  only  5  out  of  his  8  cases,  and  it  would  appear  probable  that  in 
many  instances,  at  least,  such  a  combination  is  purely  accidental;  for,  if 
renal  lesions  played  anything  like  the  prominent  part  assigned  to  them  by 
Winter  and  his  followers,  premature  separation  of  the  placenta  would  be 
frequently  observed,  since  nephritis  complicating  pregnancy  is  by  no  means 
uncommon. 

Multiparity  would  appear  to  be  a  predisposing  cause,  only  19.2  per  cent 
of  the  cases  collected  by  Holmes  having  been  noted  in  primipara?.  More- 
over, the  frequency  of  the  accident  increases  directly  with  the  number 
of  pregnancies,  and  the  advocates  of  the  endometritis  theory  believe  that 
these  facts  add  to  the  force  of  their  arguments. 

Any  of  these  conditions  may  come  into  play  during  pregnancy  or  at 
the  time  of  labour.     On  the  other  hand,  certain  aetiological  factors  cannot 


Fig.  611.  Fig.  612. 

Figs.  611,  612. — Premature  Separation  of  Placenta  with  External  Hemorrhage   (Winter). 

become  operative  until  labour  has  set  in.  Among  these  may  be  mentioned 
traction  exerted  by  an  abnormally  short  umbilical  cord,  as  well  as  a  sud- 
den diminution  in  the  bulk  of  the  uterine  contents  following  the  birth  of 
the  first  child  in  a  twin  pregnancy  or  the  too  rapid  expulsion  of  a  large 
amount  of  amniotic  fluid  in  hydramnios. 

Pathology.- — As  the  result  of  the  separation  of  the  placenta  the  vessels 
traversing  the  decidua  serotina  are  torn  through,  and  since  the  uterus, 
which  is  still  distended  by  the  product  of  conception,  is  unable  to  retract  in 
the  usual  manner  and  compress  them,  haemorrhage  must  inevitably  result. 
The  blood  may  make  its  way  to  the  exterior  or  be  retained  within  the 
uterus.     According  to  Goodell,  the  latter  condition,  which  constitutes  what 


PREMATURE   SEPARATION   OP   THE    PLACENTA  715 

is  termed  concealed  hcemorrhage,  is  liable  to  occur  (1)  when  there  is  ;m 
effusion  of  blood  behind  the  placenta,  its  mar-ins  still  remaining  adherent; 
(2)  when  the  placenta  is  completely  separated,  while  the  membranes  retain 
their  attachmenl  to  the  uterine  wall;  (3)  when  the  blood  gains  access  to  the 
amniotic  cavity  after  breaking  through  the  membranes;  and  (4)  when  the 
head  is  so  accurately  applied  to  the  lower  uterine  segment  that  the  blood 
cannot  make  its  way  past  it.  In  about  two  thirds  of  the  cases,  however, 
the  membranes  are  dissected  up  and  the  blood  eventually  escapes  from  the 
cervix.  Thus,  in  a  series  of  300  cases  collected  by  Goodell  and  Holmes,  the 
haemorrhage  was  external  in  193  and  concealed  in  113. 

Rigby,  in  1780,  directed  particular  attention  to  this  condition,  and  desig- 
nated the  haemorrhage  resulting  from  it  as  accidental,  as  contrasted  with 
the  unavoidable  hemorrhage  following  the  partial  separation  of  a  placenta 
praevia.  In  many  instances  the  prematurely  separated  organ  may  be  seri- 
ously damaged  by  the  haemorrhage;  and  especially  in  the  cases  complicated 
by  albuminuria,  a  large  part  of  its  bulk  is  often  found  occupied  by  fresh 
red  infarcts  or  placental  apoplexies.  In  other  cases,  however,  the  only 
anatomical  indication  of  the  condition  visible  in  the  placenta  will  be  a  few 
blood-clots  upon  its  maternal  surface  or  about  one  of  its  margins. 

Clinical  History. — Premature  separation  of  the  placenta  may  occur  dur- 
ing the  latpr  months  of  pregnancy  or  at  the  lime  of  labour.  In  the  former 
case,  the  resulting  external  or  concealed  haemorrhage  is  soon  followed  by 
the  onset  of  uterine  contractions.  In  either  event,  if  the  loss  of  blood  is 
marked,  the  patient  presents  signs  of  aj;;ut^&na?ir4a,  and  passes  into  a  condi- 
tion of  profound  shock  which  may  end  fatally  if  delivery  is  not  effected 
promptly. 

In  concealed  haemorrhage  the  uterus  gradually  becomes  of  a  size  con- 
siderably larger  than  would  normally  correspond  to  the  duration  of  the 
pregnancy,  and  assumes  an  almost  ligneoujjeojisistency,  so  that  the  results 
of  palpation  become  very  indefinite.  At  the  same  time  the  patient  com- 
plains of  intense  pjilL  On  the  other  hand,  when  the  haemorrhage  is  exter- 
nal, there  is  little  or  no  enlargement  of  the  uterus,  and  the  pain  is  less  \ 
severe.  In  the  former  case  the  pain  and  shock  are  often  attributed  to 
other  conditions,  and  the  patient  is  sometimes  left  to  die  undelivered. 

When  the  premature  separation  of  the  placenta  occurs  at  the  time  of 
labour  as  the  result  of  traction  upon  an  abnormally  short  cord,  or  of  the 
sudden  partial  emptying  of  the  uterine  cavity  in  twin  pregnancy  or  hy- 
dramnios,  external  haemorrhage  generally  occurs,  and  in  the  former  case  the 
foetal  heart  sounds  become  imperceptible. 

In  very  exceptional  instances  the  placenta  may  become  separated  from 
its  attachment  during  the  course  of  an  otherwise  normal  labour,  and  be 
extruded  in  front  of  the  child.  Xo  doubt  most  of  the  recorded  cases  were 
really  instances  of  placenta  praevia,  although  now  and  again,  as  in  the  case 
reported  by  Munehmeyer,  such  an  accident  may  occur  even  when  the  pla- 
centa is  inserted  normally — prolapse  of  the  placejrta. 

Diagnosis. — The  appearance  of  a  cute,  anaemia .  with  manifestations  of 
shock,  in  a  patient  in  the  later  jnontlisj)lju'egnancv_should  always  suggest 
the  possibility  of  concealed  intra-u^erin^Jraemorrhage,  though  similar  symp- 


' 


716  OBSTETRICS 

toms  may  follow  the  r^pjure^>fan advanced  ex^a^uterinej)regnancj^  or  the 
very  exceptional  cases  of  spimtaneous,  rupture  of  the  uterus.  In  many 
instances  the  diagnosis  is  placed  beyond  doubt  by  the  large  size  of  the 
uterus  and  its  ligneous  consistence,  though  usually  it  is  arrived  at  mainly 
by  exclusion. 

When,  however,  the  hemorrhage  is  external,  the  diagnosis  is  rendered 
practically  positive  by  the  failure  to  demonstrate  the  presence  of  a  placenta 
previa,  though,  of  course,  it  is  impossible  to  differentiate  the  rare  cases 
of  rupture  of  the  circular  sinus  of  the  placenta  to  which  Budin  has  directed 
our  attention.  When  the  accident  occurs  during  labour  and  is  attended 
by  some  loss  of  blood,  the  symptoms  are  suggestive  of  those  following 
rupture  of  the  uterus,  though  the  latter  accident  rarely  occurs  except  after 
a  prolonged  second  stage,  while  premature  separation  may  occur  at  any 
period  of  labour. 

In  the  exceptional  instances  in  which  the  hemorrhage  is  entirely  retro- 
placental,  a  localized  elevation  of  the  corresponding  portion  of  the  uterine 
wall  can  occasionally  be  detected  on  palpation. 

Prognosis. — Accidental  hemorrhage,  whether  external  or  concealed,  is 
one  of  the  most  serious  complications  of  pregnancy  and  labour,  practically 
all  of  the  children  and  mamy  of  the  mothers  perishing.  Thus,  G-oodell  and 
Holmes  report  a  maternal  "and  fcetal  mortality  of  50.9  per  cent  and  94.4 
per  cent,  and  of  32.2  per  cent  and  85.8  per  cent  respectively. 

Treatment. — In  the  more  marked  forms  the  life  of  the  mother  can  be 
saved  only  by  prompt^evacuation  of  the  uterus.  On  the  other  hand,  when 
the  separation  is  partial  and  theloss  of  blood  but  slight,  the  accident  may 
be  without  serious  significance.  In  the  latter  class  of  cases  an  expectant 
treatment  should  be  pursued,  and  labour  allowed  to  take  its  natural  course, 
interference  being  indicated  only  when  the  symptoms  become  urgent.  On 
the  other  hand,  if  the  patient  presents  signs  of  acute  hemorrhage,  whether 
of  the  concealed  or  external  variety,  the  uterus  should  be  emptied  with  the 
least  possible  delay,  in  order  that  it  may  retract  and  thus  compress  the 
bleeding  vessels. 

If  labour  has  not  yet  set  in,  the  cervix  should  be  dilatgcWnstrumentaily 
to  a  sufficient  extent  to  permit  the  introduction  of  a  Champetier  de  Ribes 
balloon,  and  as  soon  as  the  internal  os  has  become  obliterated  further  dilata- 
tion should  be  effected  by  Harris's  method.  On  the  other  hand,  if  the  con- 
dition of  the  cervix  permits,  manual  dilatation  should  be  employed  from 
the  outset  and  the  child  promptly  delivered  by  vgr§ion  or  forceps,  as  ap- 
pears most  advisable.  In  the  rare  cases  in  which  the  symptoms  are  urgent 
and  the  cervix  so  rigid  that  dilatation  cannot  be  promptly  accomplished, 
deep  cervical  incisions  should  be  made  without  hesitation,  and  united  by 
sutures  after  the  extraction  of  the  child. 

Not  uncommonly  the  tonicity  of  the  uterus  has  been  so  impaired  by  the 
loss  of  blood  and  the  distention  to  which  it  has  been  subjected  that  it  fails 
to  contract  and  retract  during  the  third  stage  of  labour,  and  as  a  result 
profuse  post-partum  hemorrhage  may  follow.  This  possibility  should 
always  be  borne  in  mind,  and  the  operator  should  have  in  readiness  the 
necessary  materials  for  packing  the  uterus  at  a  moment's  notice. 


\ 


PLACENTA    PILKYIA 


717 


Placenta  Praevia. — The  most  common  cause  of  ante-partum  hfemorrluge 
is  the  partial  separation  of  a  placenta  implanted  in  the  neighbourhood  of  the 
internal  os — placenta  praevia. 

Our  knowledge  concernriig  this  abnormality  may  be  Baid  to  date  from 
the  end  of  the  seven t cent h  and  the  beginning  of  the  eighteenth  centuries, 
Portal,  in  L685,  and  Schacher,  in  1TU!J,  having  accurately  described  the 
condition  from  a  clinical  and  an  anatomical  point  of  view.  Notwithstand- 
ing the  fact  that  Smellie,  William  Hunter,  and  Rigby  were  well  acquainted 
with  placenta  praevia  and  its  dangers,  very  little  advance  was  made  in  our 
knowledge  concerning  it  until  Barnes  promulgated  his  views  as  to  its  mode 
of  production  and  the  methods  of  controlling  the  haemorrhage  arising  from 
it.  Since  then  many  investigators  have  busied  themselves  in  searching  for 
its  mode  of  origin  and  the  most  suitable  treatment.  An  excellent  histor- 
ical resume  is  contained  in  von  HerfFs  monograph. 

In  this  condition,  the  placenta,  instead  of  being  implanted  high  up  upon 
the  anterior  or  the  posterior  wall  of  the  uterus,  overlaps  the  internal  os 


Fig.  613.  Tig.  614. 

CENTRAL 

Figs.  613,  614. — Showing  Diffekext  Modes  of  Placental  Insertion. 
Modified  from  American  Text-Book .) 


to  a  greater  or  lesser  extent,  thereby  becoming  accessible  to  the  examining 
finger.  Ordinarily,  three  varieties  are  distinguished:  Pla.centa  prcevia  cen- 
tralis, lateralis  or  'partialis,  and  marginalis.  In  the  first  the  internal  os  is 
completely 'covered  by  placental  tissue,  which  is  adherent  to  its  margins; 
in  the  second  the  placenta  encroaches  more  or  less  upon  the  internal  os, 
but  does  not  completely  cover  it;  in  the  third  the  placenta  is  implanted 
higher  up,  its  lower  margin  becoming  palpable  only  after  the  cervix  has 
undergone  a  certain  degree  of  dilatation  (Figs.  613  and  614). 


718 


OBSTETRICS 


Strictly  speaking,  only  the  central  and  partial  varieties  are  entitled  to 
be  looked  upon  as  true  instances  of  placenta  previa,  since  in  the  third  form 
the  placental  tissue  does  not  overlap  the  internal  os  during  pregnancy. 
Moreover,  it  is  not  always  possible  to  differentiate  between  the  first  two  be- 
fore labour,  for  the  reason  that  a  partial  placenta  praevia,  which  may  com- 
pletely cover  the  internal  os  during  pregnancy,  will  encroach  upon  only  one 

margin  of  it  when  dila- 
tation is   complete.     In 
Wj     both    of   these    varieties 
partial  separation  of  the 
placenta    is    an    inevitable* 
consequence  of  the  forma-v 
tion    of    the    lower    uterine  \ 
segment    and    the    dilatation  / 
of  the  cervix.     This  is  always  S 
associated    with    haemorrhage, 
which  was  therefore  designated 
by  Rigby  as  unavoidable.    In  pla- 
centa   prsevia    marginalis,    on    the 
other    hand,    haemorrhage    does   not 
always  occur,  and  as  the  placental  tissue 
can  be  felt  only  after  dilatation  has  pro- 
ceeded to  a  certain  extent,  the  existence 
of  the  condition  is  frequently  unrecog- 
nised.    Such  eases  are  closely  related  to 
the  so-called  vicious  insertion  of  the  pla- 
centa described  by  Pinard  and  his  pu- 
pils, which  is  of  frequent  occurrence. 

Frequency. — Placenta  praevia  is  for- 
tunately a  comparatively  rare_.complica- 
tion,  although  the  statements  as  to  its 
frequency  vary  considerably.  Thus,  W. 
Miiller,  whose  statistics  were  based  upon 
876,432  labours,  stated  that  it  occurs 
once  in  1,078  cases,  while  Lomer  and 
Tarnier,  on  the  other  hand,  estimated 
its  incidence  to  be  once  in  723  and  207  cases  respectively.  In  all  proba- 
bility it  would  be  correct  to  say  that  it  is  met  with  about  once  in  1,000 
cases  in  private,  as  compared  with  once  in  250  cases  in  hospital  practice. 

Moreover,  there  is  considerable  variation  in  the  statements  as  to  the 
relative  frequency  of  the  several  varieties,  though  it  is  generally  admitted 
that  the  partial  form  is  the  one  most  frequently  observed.  Thus,  Koblanck 
and  Strassmann  observed  the  central  variety  in  18.4  and  23.8  per  cent,  the 
lateral  in  64.5  and  61.5  per  cent,  and  the  marginal  in  17.1  and  15.2  per 
cent  of  their  placenta  praevia  cases  respectively.  Pinard,  on  the  other  hand, 
states  that  he  has  never  met  with  a  placenta  which  was  uniformly  adherent 
to  the  margins  of  the  internal  os,  and  that  the  marginal  is  the  most  frequent 
variety.     In  favour  of  this  view  he  adduces  the  fact  that  he  had  observed 


Fig.  615 


Placenta   Pe.evia,   est   tvhich 

no  Attempt  at  Delivery  had  been 
Made  (Ahlfeld). 


PLACENTA  I'i;j;via 


19 


the  so-called  vicious  insertion  in  28.12  per  cen.1  of  all  normal  labours.  His 
conclusions  must,  however,  be  accepted  with  reserve,  since  they  are  b 
upon  the  measurement  of  the  distance  of  the  margin  of  the  placenta  from 
the  point  of  rupture  of  the  membranes,  as  determined  from  the  examina- 
tion of  the  after-birth,  and  it  is  clear  that  such  a  mode  of  investigation  is 
not  above  reproach. 

/Etiology. — Concerning  the  aetiology  of  placenta  praevia  comparatively 
little  is  known.  Two  factors,  however,  appear  to  favour  its  occurrence — 
endometritis  and  multiparitv. 

The  abnormality  occurs  comparatively  rarely  in  primiparae,  and  increases 
in  frequency  wjthj^hjjjiuniber  of  children  which  the  individual  has  borne. 
This  point  is  strikingly  illustrated  by  th^  following  figures  of  Doranth, 
which  are  based  upon  30,796  labours  occurring  in  Chrobak's  clinic.  Pla- 
centa praevia  was  noted  in  0.17,  0.48,  0.65,  1.37,  1.28,  and  3.39  per  cent 
of  the  patients,  according  as  they  had  given  birth  to  1,  2,  3,  4,  5,  or  6  chil- 
dren respectively;  whereas,  when  the  number  of  children  varied  between  7 
and  10,  the  percentage  was  5.51. 

The  occurrence  of  placenta  praevia  is  not  only  favoured  by  the  absolute 
numbjn^of  childrent15ul  also  by  the  rapidity  with  which  the  labours  have 
followed  one  another,  Strassmann  findingtRat  the  average  age  of  his  pa- 
tients was  32.9  years,  and 
that  the  average  number 
of  labours  was  6.38. 

Mode  of  Formation. — 
The  older  authorities  be- 
lieved that  placenta  prae- 
via was  due  to  the  primary 
implantation  of  the  ovum 
in  the  lower  portion  of 
the  uterus,  or  to  the  sep- 
aration from  its  attach- 
ment of  a  normally  im- 
planted ovum,  which,  fall- 
ing to  the  lower  portion 
of  the  uterus,  contracted 
new  connections  just  be- 
fore escaping  through  the 
cervix.  Later  it  was 
urged  that  such  a  view 
failed  to  explain  the  pro- 
duction of  the  central 
variety,  as  it  was  incon- 
ceivable that  the  minute 
ovum  could  be  prevented 
from    escaping   from   the 

uterus  sufficiently  long  to  permit  the  formation  of  attachments  between  it 
and  the  margins  of  the  internal  os.  At  the  same  time,  when  one  recalls 
the  fact  that  with  the  uterus  in  its  normal  anteflexed  position,  the  region  of 


Serotina 


Reflexa 


Fig.  616. — Diagram  illustrating   Hofiieier"s   Theort  of 
the  Formation  of  Placenta  Prjevia. 


720  OBSTETRICS 

the  internal  os  is  frequently  at  a  higher  level  than  the  fundus,  such  an 
occurrence  is  not  so  surprising  as  would  appear  at  first  sight. 
,  Notwithstanding  these  objections,  the  former  view  was  generally  ac- 
)  cepted  until  1888,  when  Hofmeier  and  Kaltenbach  advanced  the  theory  that 
a  part  of  the  placenta  developed  from  a  portion  of  chorion  in  contact  with 
the  decidua  reflexa!  As  pregnancy  advanced,  this  so-called  reflexa  placenta 
gradually  bridged  over  the  internal  os  and  eventually  came  in  contact  and 

L fused  with  the  decidua  vera,  after  which  vascular  connections  with  the 
uterine  wall  became  established  (Fig.  616). 

This  view  at  once  met  with  very  favourable  consideration,  and  at  the 
1897  meeting  of  the  German  Gynaecological  Congress  was  again  strongly 
advocated  by  Hofmeier.    At  the  same  time,  while  stating  that  he  had  ex- 
amined numerous  specimens  which  appeared  to  substantiate  this  mode  of 
origin,  he  admitted  that  it  was  not  the  only  manner  in  which  a  placenta 
prasvia  might  originate;  inasmuch  as  in  certain  instances  the  extension  of 
/  the  placental  area  might  be  rendered  possible  by  a  process  of  cleavage  in  the 
/  decidua  vera,  as  the  result  of  which  the  margin  of  the  organ  would  extend 
\  beyond  the  serotina.    Should  such  a  process  extend  downward,  it  was  read- 
'  ily  conceivable  that  the  placenta  might  grow  on  either  side  of  the  internal 
os,  and,  as  the  latter  became  obliterated,  completely  cover  it.     At  that 
time  Peters's  ovum  had  not  been  described,  so  that  Hofmeier  was  not 
aware  that  an  analogous  process  probably  occurs  in  every  pregnancy  at  the 
normal  placental  site.    Ahlfeld  was  not  convinced  by  Hofmeier's  arguments, 
and  contended  that  the  old  theory  of  primary  low  implantation  applied  to 
the  great  majority  of  cases. 

Strassmann,  in  1901,  pointed  out  that  one  of  the  most  important  factors 
in  the  development  of  placenta  prsevia  was  to  be  found  in  dg|ecijjie_ 
vascularization  of  the  decidua,  the  result  of  inflammatory  or  atrophic 
cjmnges7TturTaTEer"beJrrg  favoured  by  repeated  and  closely  following  preg- 
nancies. Such  conditions,  he  maintained,  limit  the  amount  of  blood  going 
to  the  placenta,  so  that  in  order  to  obtain  its  requisite  supply  of  nutriment 
it  becomes  necessary  for  it  to  spread  over  a  greater  area  of  attachment, 
and  in  so  doing  its  lower  portion  occasionally  approaches  the  region  of 
the  internal  os,  completely  or  partially  overlapping  it  as  the  case  may  be. 
Plausibility  is  lent  to  such  a  view  by  the  fact  that  the  placenta  in  this  ab- 
normality is  spread  over  a  greater  area  of  the  uterus  than  usual,  while  at 
the  same  time  it  is  often  considerably  thinner. 

•  In  view,  therefore,  of  Peters's  work  upon  the  normal  implantation  of 
(the  ovum  and  the  development  of  the  decidua  reflexa,  as  well  as  Strass- 
Lmann's  theoretical  deductions,  it  appears  probable  that  in  most  cases  pla- 
centa previa  results  from  the  primaix  implantation  of  the  ovum  in  the 
lower, portion  of  the  uterus,  associated  with  extensive  cleavage  of  the  de- 
V  ciclua_vera^  by  \vMcnrhe  extension  of  the  placenta  to  the  region  of  the 
jinternal  os  is  facilitated.  At  the  same  time  the  possibility  of  its  occasional 
/development  from  a  reflexa  placenta  must  be  admitted. 

Very  exceptionally,  as  reported  by  von  Weiss,  Keilmann,  Ponfick,  and 
other's,  a  part  of  the  placenta  is  developed  upon  the  upper  portion  of  the 
cervix.     The  possibility  of  such  an  occurrence  must  be  admitted,  and  is 


PLACENTA   PREVIA  721 

sustained  by  the  observation  of  Kiislner,  that  in  multiparous  women  the 
lining  of  the  upper  part  of  the  cervical  canal  occasionally  becomes  indis- 
tinguishable from  that  of  the  Lower  portion  of  the  uterus. 

Symptoms. — The  most  characteristic  symptom  of  placenta  praevia  is  /y 
hemorrhage,  which  usually  does  not  appear  until  after  the  gasenth  moiith 
of  p^egnjmc}^'    At  the  same  time  it  is  probable  that  not  a  few  cases  of      Zr5* 
abortioiiare  duo  to  this  condition,  although  the  true  state  of  affairs  usually 
escapes  observation.     I  have  seen  several  abortions  in  the  third  month 
which  were  clearly  due  to  this  abnormality. 

The  haemorrhage  frequently  comes  on  without  warning  in  a  pregnant 
woman  _who  has  previously  considered  herself  in  jjejfect  health.  Occa- 
sionally it  makes  its  first  appearance  while  the  patient  is  asleep,  so  that 
on  awakening  and  feeling  the  bedclothes  moist,  she  is  surprised  to  find  that 
she  is  lying  in  a  pool  of  blood.  Ordinarily,  the  initial  bleeding  ceases  spon- 
taneously, to  recur  again  when  least  expected,  though  in  rare  instances  the 
first  haemorrhage  may  be  so  profuse  as  to  prove  fatal.  In  other  cases  the 
bleeding  does  not  cease  entirely,  there  heing  a  continuous  discharge  of 
small  quantities  of  a  blood-stained  fluid,  which  eventually  so  weakens  the 
woman  that  a  comparatively  slight  acute  haemorrhage  may  he  sufficient  to 
cause  death.  In  a  certain  proportion  of  cases,  particularly  when  the  inser- 
tion is  marginal,  the  bleeding  does  not  appear  until  the  time  of  labour, 
when  it  may  vary  from  a  slight,  blood-stained  discharge  to  a  profuse  or 
even  fatal  haemorrhage.  As  a  rule,  it  is  less  copious  in  this  than  in  the 
other  varieties. 

The  mode  of  production  of  the  haemorrhage  is  readily  understood  when 
one  recalls  the  changes  which  take  place  in  the  lower  uterine  segment  and 
in  the  cervix  in  the  later  weeks  of  pregnancy  and  at  the  time  of  labour. 
When  the  placenta  is  inserted  centrally,  it  is  evident  that  as  dilatation  of 
the  internal  os  progresses  the  tissue  connecting  the  placenta  with  its  mar- 
gins must  inevitably  be  torn  through,  the  rupture  being  necessarily  followed 
by  haemorrhage  from  the  intervillous  spaces  and  from  the  vessels  of  the 
decidua.  Moreover,  as  the  lower  uterine  segment  becomes  developed,  it  is 
impossible  for  the  ovum  to  follow  its  retraction,  and  consequently  the 
connection  between  it  and  the  placenta  must  of  necessity  be  more  or  less 
completely  severed  and  haemorrhage  result.  At  the  same  time,  the  bleed- 
ing is  favoured  by  the  fact  that  it  is  impossible  for  the  stretched  fibres  of 
the  lower  uterine  segment  to  compress  the  torn  vessels,  as  is  the  case 
when  the  placenta  becomes  separated  during  the  third  stage  of  a  nor- 
mal labour. 

As  the  placenta  praevia  occupies  the  lower  portion  of  the  uterus,  it 
interferes  with  the  accommodation  between  it  and  the  foetal  head,  and 
consequently  abnormal  presentations,  are  unusually  frequent,  Muller 
having  noted  272  transverse  and  107  breech  presentations  in  1,148 
cases. 

In  normal  labour  all  danger  is  ordinarily  past  with  the  completion  of 
the  second  stage;  but  in  placenta  praevia,  as  a  result  of  abnormal  adhesions 
or  an  excessively  large  area  of  attachment,  the  process  of  separation  is  some- 
times interfered  with.    As  a  result,  profuse  haemorrhage  not  infrequentlv 
47 


722  OBSTETRICS 

occurs  after  the  birth  of Jh^jchild,  and  exceptionally  the  manual  removal  of 
the  placenta  becomes  necessary. 

Diagnosis. — Placenta  praevia  should  always  be  suspected  in  patients  suf- 
fering from  uterine  haemorrhage  in  the  second  half  of  pregnancy,  and  its 
possibility  should  be  borne  in  mind  until  a  careful  examination  has  revealed 
some  other  satisfactory  explanation  for  its  origin.  In  the  great  majority 
of  cases  the  ceryixis  softer  and  more  succulentj-han  usual,  and  its  canal 
is  more  or  less  patulous,  so  that  but  little  difficulty  is  experienced  in  carry- 
ing the  finger  through  the  internal  os  and  feeling  the  characteristic  sjDonge- 
like  placental  tissue,  or  at  least  making  out  a  soggy,  thick  substance  lying 
between  the  finger  and  the  presenting  part.  When,  however,  the  cervix 
is  not  patulous  it  should  be  dilated,  under  anaesthesia  if  necessary,  suffi- 
ciently to  permit  the  introduction  of  the  finger,  which  is  then  passed 
through  the  internal  os  and  swept  around  the  adjacent  portion  of  the  lower 
uterine  segment,  when  the  presence  or  absence  of  the  abnormality  can  be 
positively  determined.  It  is  true  that  such  a  procedure  occasionally  re- 
sults in  the  induction  of  premature  labour;  but  the  risk  is  nevertheless 
uite  justifiable,  since  we  possess  no  other  means  of  arriving  at  a  definite 
iagnosis,  which  should  be  made  at  any  cost  on  account  of  the  very  serious 
nenace  which  the  existence  of  the  condition  offers  to  the  life  of  the 
atient. 

Prognosis. — The  prognosis  is  always  serious.  According  to  Miiller, 
■  *  \ under  expectant  treatment  the  maternal  mortality  varied  from  j36__to_40 
*.  l  p_er  cent,  while  for  the  children  it  was  about  66  per  cent,  one  half  of  those 
^  *  which  are  born  alive  perishing  within  the  first  ten  days  following  delivery. 
The  clanger  to  the  mother  arises  primarily  from  haemorrhage,  which  is  usu- 
ally the  direct  result  of  the  condition,  though  occasionally  it  may  be  due 
to  deep  cervical  tears  resulting  from  too  hasty  artificial  dilatation  or  the 
extraction  of  the  child  through  an  imperfectly  dilated  cervix.  Moreover, 
such  patients  are  paj^icularly  prone  to  jmerperal  infection,  which  is  favoured 
by  the  presence  of  the  thrombosed  sinuses  in  the  lower  uterine  segment. 

The  foetal  mortality  is  due  in  great  part  to  the  fact  that  many  of  the 
children  are  born  some  weeks  or  months  prematurely.  In  many  instances 
thej'  perish  from  asphyxiation,  the  result  of  placental  haemorrhage,  while 
occasionally  they  succumb  during  attempts  at  extraction  through  an  im- 
perfectly dilated  cervix. 

Nowadays,  the  maternal  mortality  depends  upon  the  mrifitv  of  the 
placenta  praevia,  the  method  of_delivery,  and  the  condition  of  the  patient 
when  first  seen.  Thus,  in  178  cases  reported  by  Hofmeier,  Behm,  and 
Lomer,  and  treated  by  11  different  obstetricians  by  combined  version  by 
the  Braxton  Hicks  manoeuvre,  the  maternal  mortality  was  4.5  per  cent, 
whereas  93  cases  treated  by  the  three  operators  mentioned  showed  a  mor- 
tality of  only  1  per  cent.  Koblanck  reports  a  death-rate  of  3.8  per  cent 
in  467  cases  treated  in  the  Frauenklinik  in  Berlin,  and  Strassmann  one  of 
5  per  cent  in  100  cases  which  he  delivered  personally.  According  to  their 
figures,  the  prognosis  is  from  3  to  8  times  more  serious  in  central  pla- 
centa praevia  than  in  the  other  varieties.  Moreover,  the  mortality  depends 
upon  the  condition  of  the  patient  when  first  seen,  it  being  evident  that 


I'LACKNTA    I'K.KVIA 


723 


women  who  have  suffered  from  profuse  and  repeated  bleeding  have  far 
less  chance  of  recovery  than  those  who  come  under  observation  after  the 
first  slight  haemorrhage. 

In  fortunately,  the  foetal  mortality  has  shown  comparatively  little  de- 
crease  in  recent  years,  Kustner  and  Strassmann  giving  percentages  of  35 
and  61.22  respectively.  This  difference  is  probably  due  to  the  fact  that  the 
former  employed  the  rubber  bag  extensively,  whereas  the  latter  treated  his 
cases  by  the  Braxton  Hicks  method  of  version  and  gradual  extraction.  A 
very  great  improvement  in  this  respect  is  hardly 
to  be  anticipated  on  account  of  the  large  num- 
ber of  premature  children  with  which  one  has 
to  deal. 

Treatment. — On  account  of  the  danger  of 
profuse  and  unexpected  haemorrhage,  preg- 
nancy or  labour,  as  the  case  may  be,  sh^ould 
be  terminated  in  the  most  conservative  manner 
assoon  as  possible  after  a  placenta  prasvia  has 
been  positively  diagnosed.  There  is  no  single 
method  of  treatment  applicable  to  all  classes, 
and  the  obstetrician  who  understands  how  to 
differentiate  his  cases  will  obtain  the  best 
results. 

If  the  diagnosis  is  made  during  pregnancy, 
the  cervix  should  be  dilated  by  means  of  the 
finger  or  by  the  Goodell  or  Hegar  instrument 
sufficiently  to  permit  the  introduction  of  two 
fingers.  This  having  been  attained,  further 
treatment  will  depend  upon  whether  the  child 
is  viable  or  not.  In  the  former  case  the  best 
\j  j.  results  are  obtained  by  the  introduction  of  a 
jChampetier  de  Bibes  balloon  after  rupture  of 

I the  membranes  or  perforation  of  the  placenta, 

according  as  one  has  to  deal  with  a  lateral  or 
central  insertion,  dilatation  being  hastened  by 
attaching  a  2-pound  weight  to  the  end  of  the 
tube  by  a  string  and  suspending  it  over  the 
foot  of  the  bed.  On  the  other  hand,  if  the 
child  is  not  viable,  equally  good  results  are 
more  readily  obtained  by  bringing  down  a  foot 
by  Braxton  Hicks's  manoeuvre  and  using  the 
breech  of  the  child  as  a  tampon  to  control  fur- 
ther bleeding.  If  the  hemorrhage  ceases  after  the  foot  has  been  brought 
down,  the  expulsion  of  the  child  may  be  left  to  Nature;  but  if  the  oozing 
continues,  gentle  traction  should  be  made  upon  the  leg  so  as  to  compress  the 
placenta  with  the  child's  buttocks.  Whichever  method  is  employed,  extrac- 
tion should  not  be  attempted  until  the  cervix  is  completely  dilated,  or  at 
least  sufficiently  so  as  to  permit  the  ready  passage  of  the  head.  Too  much 
haste  is  liable  to  cause  deep  cervical  tears,  giving  rise  to  profuse  haemor- 


-L 


Fig.  617. — Fcetus  partially  ex- 
tracted from  a  Patient  Dy- 
ing of  Placenta  Previa, 
showing  how  it  acts  as  a 
Tampon  (Leopold). 


724  OBSTETRICS 

rliage  and  requiring  the  application  of  sutures,  while  in  other  instances 
serious  difficulty  may  be  encountered  in  delivering  the  child. 

Generally  speaking,  better  results  will  be  obtained  in  private  practice 
by  the  employment  of  Braxton  Hicks"s  bipolar  version,  no  matter  what  may 
be  the  condition  of  the  child,  for  the  reason  that  the  average  practitioner 
will  rarely  be  equipped  with  a  suitable  balloon  and  the  necessary  parapher- 
nalia for  its  introduction.  In  hospital  practice,  however,  its  employment 
has  undoubtedly  aided  materially  in  diminishing  the  fcetal  mortality. 

In  verv  exceptional  instances  in  primiparous  women,  the  cervix  may  be 
so  rigid  that  it  is  impossible  to  dilate  it  sufficiently  to  permit  the  employ- 
ment of  either  of  the  above-mentioned  procedures.  Under  such  circum- 
stances a  tight  cervical  andya^n2^1j2ack_of  stpj^^ejlgjim^JimTdage  should 
be  applied!  This  will  check  the  haemorrhage  for  the  time  being,  and  after 
remaining  in  place  for  a  few  hours  will  usually  bring  about  sufficient  dila- 
tation to  permit  the  employment  of  whatever  manoeuvres  may  be  deemed 
necessary. 

At  the  time  of  labour,  the  treatment  depends  upon  the  degree  of  dilata- 
tion and  the  condition  of  the  patient.  If  the  cervix  is  obliterated,  imme- 
diate delivery  by  version  or  forceps  is  indicated.  On  the  other  hand,  if  the 
dilatation  is  only  partial,  the  hemorrhage  slight,  and  the  placenta  inserted 
marginally,  good  results  frequently  follow  rupture  of  the  membranes,  since 
the  placenta  is  then  able  to  follow  the  retracting  uterine  wall.  In  all  other 
cases  I  prefer  to  complete  the  dilatation  by  Harris's  method,  provided  the 
consistency  of  the  cervix  is  such  that  it  appears  probable  that  the  procedure 
can  be  readily  and  safely  employed.  The  membranes  are  then  ruptured  or 
the  placenta  is  torn  through,  according  as  one  has  to  deal  with  a  partial 
or  complete  placenta  previa,  after  which  the  child  is  turned  and  promptly 
extracted.  I  have  obtained  very  satisfactory  results  by  this  method,  as 
have  also  Harris,  Didry,  and  many  others. 

If,  however,  it  does  not  appear  likely  that  the  cervix  can  be  read- 
ily dilated  manually,  or  that  such  a  procedure  is  liable  to  give  rise 
to  deep  cervical  tears,  it  is  advisable  to  make  use  of  a  Champetier  de 
Ribes  balloon  or  to  perform  version  by  the  bipolar  method  of  Braxton 
Hicks,  extracting  the  child  only  after  satisfactory  dilatation  has  been 
obtained. 

If  the  patient  is  seen  at  the  beginning  of  labour  and  before  the  cervix 
has  undergone  any  great  degree  of  dilatation,  the  same  methods  should  be 
employed  as  during  pregnancy. 

Whenever  the  haemorrhage  has  been  profuse,  and  the  patient  presents 
the  subjective  sjunptoms  of  an  acute  anemia,  it  becomes  necessary  to  resort 
to  the  constitutional  measures  outlined  under  the  treatment  of  post-partum 
hemorrhage.  Occasionally,  when  the  patient  is  markedly  exsanguinated 
when  first  seen,  but  is  losing  little  or  no  blood  at  the  time,  it  is  better  to 
devote  one's  attention  to  improving  her  general  condition  rather  than  to 
attempt  immediate  delivery. 

In  view  of  the  danger  to  the  mother,  and  particularly  the  marked  foetal 
mortality  attending  placenta  previa,  as  well  as  the  fact  that  not  a  few 
children  are  sacrificed  by  Braxton  Hicks's  method  of  version,  or  by  extrac- 


POST-PARTUM   HAEMORRHAGE  (25 

tion  through  an  imperfectly  dilated  cervix,  Tait,  Donoghue,  Palmer  Dudley, 
and  others  have  recommended  the  performance  of  Caesaroan  section,  pro- 
vided the  child  is  viable  and  the  patient  in  good  condition. 

As  the  results  obtained  by  the  methods  of  treatment  outlined  above 
are  quite  satisfactory  so  far  as  the  mother  is  concerned,  ii  seems  doubtful 
whether  Cesarean  section  will  come  into  very  general  use,  particularly  as 
the  operation  is  applicable  only  to  patients  who  are  in  a  hospital,  or  the 
rich,  who  can  be  surrounded  by  every  convenience  and  safeguard.  If  such 
a  line  of  treatment  were  attempted  among  the  poorer  classes  in  their  own 
homes,  the  death-rate,  I  am  sure,  would  be  much  greater  than  that  obtained 
by  the  usual  methods.  Moreover,  as  has  been  said,  the  foetal  mortality  in 
any  case  is  not  susceptible  of  any  material  reduction,  for  the  reason  that 
the  pregnancy  is  generally  terminated  before  term,  when  the  chances  of 
extra-uterine  life  are  relatively  unfavourable.  Ehrenfest,  after  carefully 
considering  the  subject,  has  arrived  at  the  same  conclusion. 

At  the  same  time,  I  am  prepared  to  admit  that  Cesarean  section  may  be 
the  operation  of  choice  in  a  very  small  number  of  cases,  as,  for  instance, 
when  a  primipara  with  a  very  rigid  cervix  and  a  living  child  is  overtaken 
by  profuse  haemorrhage.  Such  conditions,  however,  are  so  exceptional  that 
it  appears  to  me  that  the  field  of  usefulness  for  the  operation  is  very  lim- 
ited, and  that  its  widespread  employment  would  be  productive  of  far  more 
harm  than  good. 

The  mode  of  production  and  significance  of  slight  ante-partum  haemor- 
rhage, which  sometimes  follows  intra-uterine  rupture  of  the  cord  or  the  tear- 
ing of  the  vessels  of  the  velamentously  inserted  umbilical  cord,  have  already 
been  considered  in  Chapter  XXVIII. 

Post-partum  Haemorrhage. — With  the  exception  of  the  very  rare  cases 
incident  to  inversion  of  the  uterus,  a  serious  bleeding  following  the  birth  of 
the  child  is  usually  due  to  one  of  three  causes.  Of  these  the  most  com- 
mon is  retention  of  the  partially  separated  placenta  or  of  individual  coty- 
ledons; less  often  it  is  due  to  deep  tears  involving  the  tissues  of  the  birth 
canal,  and  in  very  rare  instances  to  defective  functioning  of  the  uterine 
musculature — atony. 

2Etiology. — As  long  as  the  placenta  remains  firmly  attached  to  the  uterine 
wall  the  possibility  of  haemorrhage  is  slight,  but  when  it  has  become  par- 
tially separated,  the  normal  action  of  the  uterine  musculature  is  interfered 
with.  As  a  result,  the  torn  vessels  at  the  partially  denuded  placental  site 
are  not  constricted,  and  accordingly  more  or  less  profuse  haemorrhage  occurs. 
Imperfect  separation  of  the  placenta  can  usually  be  attributed  to  improper 
management  of  the  third  stage  of  labour,  particularly  the  too  early  and 
enenretic  employment  of  Crede's  manoeuvre.  Exceptionally,  it  may  result 
from  an  abnormally  intimate  attachment  of  the  placenta,  clue  to  a  decidual 
endometritis  or  some  other  morbid  condition.  The  retention  of  isolated 
cotyledons  or  of  a  small  succenturiate  lobe  interferes  with  the  normal  con- 
traction and  retention  of  the  uterus  in  precisely  the  same  manner  as  the 
partially  separated  placenta. 

The  part  played  by  deep  tears  of  the  generative  tract  is  perfectly  obvi- 
ous, and  will  be  considered  in  detail  in  the  following  chapter. 


726  OBSTETRICS 

In  very  rare  instances  serious  haemorrhage  may  result  from  rupture  of 
large  varicose  veins,  of  an  aneurysm  of  the  uterine  artery,  or  the  dis- 
turbance of  areas  of  thrombosis  in  the  cervix. 

Formerly,  atony  of  the  puerperal  uterus  was  considered  the  most  fre- 
quent cause  of  post-partum  haemorrhage,  but  more  careful  observation  has 
shown  that  such  a  condition  is  seldom  primary;  for,  with  the  exception  of 
the  rare  instances  in  which  it  follows  excessive  distention  of  the  uterus 
incident  to  twin  pregnancy  or  hydramnios,  serious  abnormalities  in  the 
contractile  function  of  the  uterine  musculature  are  usually  associated  with 
some  mechanical  cause,  such  as  retention  of  jDortions  of  the  placenta,  the 
presence  of  myomata  in  the  uterine  walls,  or  in  rare  cases  the  existence  of 
adhesions  between  the  uterus  and  the  surrounding  organs.  It  is  probable, 
however,  that  Veit  goes  too  far  in  denying  in  toto  the  possibility  of  a  primary 
atony,  although  the  general  tendency  to  overestimate  its  frequency  must 
be  admitted. 

The  rare  cases  of  haemorrhage  following  paralysis  at  the  placental  site,  in 
which  the  rest  of  the  organ  remains  firmly  contracted,  as  in  the  cases  re- 
ported by  Chiari,  Braun  and  Spaeth,  Olshausen,  and  others,  point  to  the 
possibility  of  a  partial  atony,  while  the  occasional  instances  in  which  pa- 
tients bleed  profusely  after  each  labour  without  demonstrable  cause,  like- 
wise afford  corroborative  evidence.  At  the  same  time  the  possible  exist- 
ence of  haemophilia  should  always  be  borne  in  mind  in  such  women,  as  in  a 
case  reported  by  Wehle. 

Clinical  History. — Haemorrhage  may  occur  either  during  or  after  the 
third  stage  of  labour.  In  the  first  class  of  cases,  as  a  rule,  it  is  the  result 
of  tears  or  of  partial  separation  of  the  placenta.  Fortunately,  haemorrhage 
dependent  upon  the  latter  cause  is  usually  not  serious,  for  the  reason  that 
in  the  vast  majority  of  such  cases  the  condition  is  only  transitory,  complete 
separation  occurring  spontaneously  as  the  result  of  uterine  contraction, 
when  satisfactory  retraction  checks  the  loss  of  blood.  Excei)tionally  the 
bleeding  may  persist  even  after  the  placenta  has  become  completely  sepa- 
rated and  lies  free  in  the  uterine  cavity.  In  such  cases,  however,  it  is  due 
either  to  tears  or  to  imperfect  functioning  of  the  uterus. 

Generally  speaking,  partial  separation  occurring  during  the  course  of 
placental  expulsion  by  the  Schultze  mechanism  is  not  accompanied  by  ex- 
ternal haemorrhage  until  the  placenta  escapes  from  the  vulva,  when  the 
large  amount  of  blood  collected  behind  it  is  suddenly  discharged.  In  Dun- 
can's mechanism,  on  the  other  hand,  the  loss  of  blood  continues  throughout 
the  entire  placental  period. 

A  haemorrhage  which  persists  after  the  extrusion  of  the  placenta  may 
be  due  to  tears,  retention  of  placental  remnants,  or  to  atony.  In  the  first 
there  is  a  steady  flow  of  bright-red  blood,  which  begins  immediately  after 
the  delivery  of  the  child.  When  the  haemorrhage  is  due  to  retention,  the 
blood  escapes  in  gushes,  which  are  apt  to  be  synchronous  with  the  uterine 
contractions,  and  frequently  in  large  clots;  whereas  in  cases  due  to  primary 
atony  there  is  a  continuous  flow  of  blood,  which  may  be  so  abundant  as  to 
cause  death  within  a  very  few  minutes. 

In  rare  instances,  even  after  the  discharge  of  the  placenta,  the  haemor- 


POST  I'Airn.M    ILKMORltHAOE  727 

rhage  may  be  concealed,  several  litres  of  blood  sometimes  accumulating  in 
the  uterine  cavity. 

The  amount  of  blood  Lost  during  a  post-partum  hemorrhage  may  vary 
from  500  to  3,000  cubic  centimetres,  the  Latter  extreme,  however,  being  usu- 
ally incompatible  with  life.  Generally  speaking,  the  effect  upon  the  patient 
depends  more  upon  her  general  condition  than  upon  the  actual  amount  of 
blood  lost.  Thus,  a  woman  who  is  already  exhausted  by  a  prolonged  labour 
or  weakened  by  antecedent  disease,  may  succumb  after  a  loss  of  from  1,000 
to  1,500  cubic  centimetres,  which  others  suffer  with  impunity.  As  a  rule, 
the  loss  of  a  small  amount  of  blood  is  not  attended  by  serious  symptoms; 
but  when  the  haemorrhage  is  profuse  the  pulse  becomes  rapid  and  com- 
pressible, the  face  becomes  pallid  and  assumes  a  drawn  appearance,  while 
at  the  same  time  the  woman  may  complain  of  disturbed  vision,  chilliness, 
and  shortness  of  breath.  In  extreme  cases  symptoms  of  air  hunger  appear, 
and  the  patient  usually  passes  into  unconsciousness  before  the  fatal  ter- 
mination. 

Diagnosis. — The  diagnosis  offers  no  difficulty,  except  in  the  rare 
instances  in  which  the  haemorrhage  has  taken  place  into  the  uterine  cavity 
and  does  not  appear  externally.  It  must,  however,  be  distinctly  stated 
that  concealed  haemorrhage  should  never  occur  if  the  condition  of  the 
uterus  is  conscientiously  watched,  although,  if  routine  precautions  are 
neglected,  the  first  indication  of  the  condition  is  occasionally  afforded  by 
the  pale  and  haggard  appearance  of  the  patient.  On  examination  the 
pulse-rate  will  be  found  greatly  accelerated,  the  uterus  markedly  increased 
in  size,  and  presenting  a  doughy  consistence  instead  of  the  characteristic 
firm,  hard  sensation  offered  by  the  normal  puerperal  organ.  Pressure  upon 
it  is  followed  by  a  copious  flow  of  blood  from  the  vagina. 

Although  the  source  of  the  haemorrhage  is  sometimes  very  hard  to 
trace,  yet  inasmuch  as  the  decision  as  to  the  proper  treatment  of  the  pa- 
tient frequently  depends  upon  its  recognition,  a  differential  diagnosis  is  of 
the  utmost  importance.  Generally  speaking,  if  the  haemorrhage  com- ' 
mences  immediately  after  the  birth  of  the  child,  it  is  due  either  to  tears 
of  the  genital  tract  or  to  partial  separation  of  the  placenta.  In  the  latter 
case  it  usually  ceases  temporarily  after  energetic  kneading  of  the  uterus, 
but  recurs  as  soon  as  it  is  allowed  to  relax.  If  manipulations  of  the  uterus 
prove  of  no  avail,  it  is  probable  that  the  haemorrhage  comes  from  a  tear, 
although  this  is  not  a  universal  rule,  since  in  a  certain  number  of  instances 
the  loss  of  blood  will  continue  until  the  placenta  is  expressed  by  Crede's 
method  or  is  removed  manually. 

Again,  a  haemorrhage  persisting  after  the  uterus  has  been  emptied,  while 
abdominal  palpation  shows  that  the  organ  itself  is  firmly  contracted,  sug- 
gests a  serious  tear  of  the  birth  canal,  which  should  be  sought  for,  and  when 
found  closed  with  sutures.  In  order  to  accomplish  this,  the  patient  having 
been  brought  to  the  edge  of  the  bed,  the  external  genitalia  are  carefully 
inspected.  If  the  perinaeum  is  intact,  the  cervix  should  be  forced  down 
towards  the  vulva  by  pressure  upon  the  fundus,  and  if  this  fails  to  bring  it 
into  view,  it  should  be  examined  by  the  fingers  in  the  vagina.  If  a  cervical 
lesion  cannot  be  detected,  the  vaginal  walls  should  be  spread  apart  by  means 


728  OBSTETRICS 

of  a  speculum  and  thoroughly  inspected.  A  haemorrhage  which  does  not 
come  on  until  ten  or  fifteen  minutes  after  the  birth  of  the  child  can  hardly 
be  due  to  a  tear. 

On  the  other  hand,  if  the  uterus  does  not  contract  and  retract  firmly 
after  the  expulsion  of  the  placenta,  or  if  it  remains  so  only  so  long  as 
kneading  is  kept  up,  the  cause  of  the  haemorrhage  must  be  sought  for  either 
in  the  retention  of  a  placental  cotyledon  or  in  atony.  Certainty  with  regard 
to  the  former  point  is  usually  obtained  by  careful  inspection  of  the  after- 
birth, a  large  defect  upon  its  maternal  surface  indicating  the  retention  of 
a  cotyledon,  while  a  more  or  less  circular  defect  in  the  membranes  a  short 
distance  from  the  placental  margin  shows  that  a  succenturiate  lobe  has  been 
left  behind.  At  the  same  time  one  should  be  careful  not  to  confound  mere 
fissures  with  defects  due  to  loss  of  tissue.  The  diagnosis  of  primary  atony 
should  be  made  only  in  those  cases  in  which  every  other  explanation  has 
been  excluded. 

Treatment. — With  proper  management,  haemorrhage  during  and  imme- 
diately following  the  third  stage  of  labour  should  be  extremely  rare.  The 
most  important  prophylactic  measures  consist  in  watching  the  condition  of 
the  uterus  after  the  birth  of  the  child,  and  not  resorting  to  Crede's  manoeu- 
vre until  the  rising  up  of  the  fundus  indicates  that  the  placenta  has  become 
completely  detached.  Premature  attempts  at  expression  are  a  frequent 
cause  of  imperfect  separation.  Again,  owing  to  the  tendency  towards  re- 
laxation following  the  birth  of  twins,  as  well  as  in  hydramnios,  concealed 
haemorrhage,  and  placenta  pra-via,  the  condition  of  the  uterus  should  be 
most  carefully  watched  for  the  few  minutes  immediately  following  the  birth 
of  the  child,  and  energetic  kneading  through  the  abdominal  wall's  prompt- 
ly resorted  to  upon  the  first  sign  of  failing  contraction. 

The  placenta  should  be  carefully  examined  after  its  expulsion,  for  the 
purpose  of  ascertaining  whether  it  is  intact  or  not.  If  it  shows  any  serious 
defect,  immediate  preparations  shordd  be  made  for  the  removal  of  the  re- 
tained portion  in  case  symptoms  supervene. 

In  the  presence  of  actual  haemorrhage,  the  treatment  varies  according 
as  the  placenta  is  still  within  the  uterus  or  has  already  been  expelled.  In 
the  former  case  the  uterus  should  at  once  be  grasped  through  the  abdom- 
inal wall  and  firmly  kneaded.  If  firm  contractions  come  on,  all  is  well,  but 
if  the  haemorrhage  continues  and  the  uterus  relaxes  as  soon  as  the  kneading 
is  stopped,  the  placenta  should  be  expressed  by  Crede's  method;  and  if 
this  cannot  be  accomplished  and  the  patient's  condition  is  alarming,  manu- 
al removal  may  become  necessary.  This  latter  procedure,  however,  should 
be  resorted  to  only  in  serious  cases,  and  the  directions  given  for  its  per- 
formance in  Chapter  XXTV  should  be  most  conscientiously  followed. 

If  the  haemorrhage  does  not  cease  after  the  delivery  of  the  placenta, 
the  cause  should  be  ascertained  and  suitable  treatment  instituted.  Tears 
should  be  located  and  their  edges  brought  together  by  sutures.  On  the 
other  hand,  if  the  haemorrhage  is  the  result  of  the  retention  of  placental 
tissue,  the  carefully  disinfected  hand  should  be  carried  up  into  the  uterus 
in  order  to  seek  for  and  remove  the  retained  cotyledon.  Under  such  cir- 
cumstances the  hand  acts  as  a  most  efficient  irritator,  causing  the  uterus 


POST-PARTUM  HiBMORRHAGE  729 

to  contract  energel  ically.  After  separating  the  retained  portion  of  placenta 
the  hand  should  nut  be  wit  hdrawn  at  once,  bnt  should  be  allowed  to  recede 
gradually  as  it  is  forced  down  by  the  contraction  of  the  fundus. 

11'  the  hsemorrhage  is  due  to  atony,  the  uterus  should  be  vigorously 
kneaded,  and  from  40  to  60  minims  of  ergot  or  of  ergotol  administered 
hypodermic-ally.  After  careful  disinfection  of  the  skin,  the  needle  should 
be  plunged  in  at  right  angles  to  the  surface,  deep  down  into  the  tissues  of 
the  thigh,  since  in  this  way  the  chances  of  abscess  formation  are  greatly 
diminished. 

If  these  measures  are  not  attended  with  the  desired  result,  a  very  hot 
intra-uterine  douche  of  several  litres  of  sterile  salt  solution  should  be  em- 
ployed. In  many  cases  this  acts  as  a  most  efficient  haemostatic,  effectively 
irritating  the  uterus  and  causing  it  to  contract  forcibly  and  permanently. 

If  the  haemorrhage  persists  in  spite  of  the  douche,  our  only  hope  of 
controlling  it  is  by  packing  the  uterus  tightly  with  sterile  gauze,  which 
should  be  introduced  according  to  the  directions  given  in  Chapter  XXIV 
(see  Fig.  -il9).  Before  resorting  to  the  use  of  the  pack  it  is  always  advisable 
to  palpate  the  interior  of  the  uterus,  as  occasionally  a  portion  of  the  pla- 
centa may  have  been  retained,  even  though  immediately  after  expulsion  the 
organ  may  ha  ye  apparently  been  entire. 

Formerly  it  was  customary  to  recommend  the  introduction  into  the 
uterus  of  ice  or  solutions  containing  vinegar,  the  perchloride  of  iron,  or 
other  astringent  substances.  Their  employment,  however,  is  not  advisable, 
since  ice  and  ordinary  vinegar  are  never  sterile,  while  the  iron  solution  ac- 
complishes its  purpose  by  the  formation  of  dense  coagula,  which  are  later 
separated  from  the  uterus  by  suppurative  processes.  Above  all,  none  of 
them  act  as  promptly  or  efficiently  as  the  pack,  the  employment  of  which, 
although  comparatively  rarely  indicated,  in  exceptional  cases  offers  the  only 
reliable  means  of  coping  with  the  condition.  For  this  reason  the  obstetri- 
cian should  always  carry  in  his  bag  the  materials  necessary  for  it,  as  they 
cannot  usually  be  obtained  promptly  in  an  emergency. 

Too  great  stress  cannot  be  laid  upon  the  importance  of  observing  the 
most  rigorous  aseptic  technique  in  every  intra-uterine  manipulation  un- 
dertaken for  the  purpose  of  checking  post-partum  haemorrhage.  The 
natural  tendency  of  the  physician  is  to  forget  all  other  risks  in  his  attempts 
to  check  the  bleeding  at  once.  Such  neglect,  however,  is  frequently  attend- 
ed by  most  serious  consequences,  the  patient  being  saved  from  death  from 
haemorrhage  merely  to  perish  of  infection  a  few  days  later.  For  this  reason, 
therefore,  the  obstetrician  will  usually  best  subserve  the  interests  of  his 
patient  by  taking  the  time  necessary  for  carefully  disinfecting  his  hands 
"before  beginning  any  manipulations.  In  fact,  the  only  exception  is  offered 
by  the  very  rare  cases  of  atonic  haemorrhage  in  which  it  appears  probable 
that  a  delay  even  of  a  few  minutes  means  inevitable  death. 

After  the  actual  haemorrhage  has  been  checked,  attention  must  be  direct- 
ed to  the  general  condition  of  the  patient.  "When  the  shock  is  not  profound 
and  the  pulse  not  particularly  rapid,  elevation  of  the  foot  of  the  bed  and 
the  application  of  hot  bottles  or  bricks  to  the  extremities  will  be  all  that  is 
needed.    In  more  severe  cases,  the  administration  of  ^  grain  of  strychnine 


730 


OBSTETRICS 


hypodermically,  3  doses  being  given  in  prompt  succession,  if  necessary,  is 
attended  by  excellent  results,  which  may  be  supjalemented  by  hypodermic 
injections  of  whisky  or  ether.  Hot  rectal  enemata  of  equal  parts  of  black 
coffee  and  salt  solution  are  also  valuable. 

When  the  patient  is  profoundly  shocked,  sterile  normal  salt  solution  in 
large  quantities — 500  cubic  centimetres  being  injected  under  each  breast, 
and  repeated  as  soon  as  absorption  has  occurred — will  prove  the  best  re- 
storative. When  the  condition  is  very  serious  and  a  suitable  canula  is 
available,  even  more  striking  results  may  be  obtained  by  administering  it 
intravenously.  Occasionally,  when  the  loss  of  blood  has  been  very  great, 
these  measures  may  be  supplemented  by  tightly  bandaging  the  extremities 
or  compressing  the  aorta,  in  the  hope  of  retaining  as  large  a  quantity  of 
blood  as  possible  in  the  upper  part  of  the  body. 

Inversion  of  the  Uterus. — This  condition  is  a  very  rare,  but  important 
cause  of  post-partum  haemorrhage.  According  to  Beckmann,  not  a  single 
case  occurred  in  250,000  labours  in  the  St.  Petersburg  Lying-in  Hospital, 


Fig.  618. — Complete  Inversion  of  Uterus  (Bumm). 


while  Madden  noted  it  only  once  in  190,833  deliveries  in  Dublin.  Many 
obstetricians  in  large  practice  have  never  seen  a  case,  or  have  met  with 
only  a  few  examples  of  the  condition.  The  historical  and  statistical  aspects 
of  the  subject  are  fully  dealt  with  in  the  articles  of  Beckmann,  Browne, 
and  Vogel. 


INVERSION   OF  THE  UTERUS  731 

Xow  and  again  the  fundus  of  the  uterus  becomes  inverted  and  comes 
into  close  contact  with  or  may  protrude  through  the  external  os;  while 
in  rare  Instances  the  entire  organ  appears  outside  of  the  vulva,  the  con- 
dition being  respectively  designated  as  incomplete  and  complete  inversion 
and  prolapse  of  the  inverted  uterus  (Fig.  618).  In  not  a  few  <-;im\s  the 
placenta  remains  attached  to  the  inverted  organ. 

etiology. — For  the  production  of  the  accident  two  factors  are  neces- 
sary: marked  laxity  of  the  uterine  walls^  particularly  at  the  placental  site, 
and  a  patulous  cervical  canal.  Inversion  may  occur  spontaneously  as  the 
result  of  the  intra-abdmninaTpressure  or  from  the  mere  weight  of  the  intes- 
tines, while  in  other  cases  it  is  attributable  to  violence  resulting  from  the 
too  vigorous  employment  of  Crede's  manoeuvre  or  to  traction  upon  the 
cord. 

Beckmann,  who  has  carefully  analyzed  100  cases  reported  in  the  litera- 
ture, believes  that  in  the  majority  of  instances  the  accident  occurs  sponta- 
neously, while  Vogel,  in  a  similar  review,  holds  that  most  cases  are  due  to 
violence.  His  contention  appears  to  be  confirmed  by  Beckmann's  statistics, 
as  only  3  of  the  100  cases  occurred  in  hospital  practice.  Indeed,  it  is  highly 
probable  that  the  accident  is  excessively  rare  when  labour  is  properly  con- 
ducted, but  that  it  occurs  more  frequently  under  the  unfavourable  condi- 
tions existing  in  private  practice,  particularly  as  conducted  by  midwives. 

The  complication  usually  follows  a  full-term  labour,  although  a  number 
of  cases  are  recorded  in  which  it  was  noted  after  abortion.  It  is  also  an 
interesting  fact  that  more  than  50  per  cent  of  the  cases  recorded  by  both 
Beckmann  and  Vogel  were  in  primiparous  women. 

Symptoms. — As  a  rule,  inversion  of  the  uterus  is  promptly  followed  by 
alarming  symptoms,  the  patient  presenting  marked  evidences  of  shock,  with 
a  rapid  pulse  and  a  tendency  to  syncope.  In  other  cases  convulsions  occur 
and  profuse  haemorrhage  is  not  infrequently^  noted.  On  the  other  hand,  the 
S}^mptoms  are  sometimes  very  slight,  and  the  condition  may  continue  for 
several  days  without  causing  any  serious  annoyance  to  the  patient. 

In  the  rare  instances  the  cervix  may  so  retract  about  the  completely 
inverted  uterus  that  strangulation  occurs,  followed  by  gangrene.  In  other 
instances  this  does  noTtake  place,~5ut  the  condition  becomes "cKronic,  neces- 
sitating operative  procedures  later. 

Prognosis. — If  the  condition  is  detected  promptly,  and  the  uterus  re- 
placed immediately,  the  prognosis  is  fair,  Beckmann  reporting  a  mortality 
of  11  per  cent.  On  the  other  hand,  if  strangulation  or  gangrene  occur,  the 
outlook  is  ominous. 

Treatment. — In  very  recent  cases  reposition  can  usually  be  effected 
without  difficulty  by  pressure  exerted  by  several  fingers  in  the  vagina,  it 
being  important  to  remember  that  the  force  should  be  directed  upward  in 
the  axis  of  the  superior  strait.  Neglect  of  this  precaution  undoubtedly 
accounts  for  a  certain  number  of  failures.  As  the  procedure  is  generally 
painful,  anaesthesia  should  be  employed. 

If  the  placenta  is  still  attached  to  the  uterus,  it  is  generally  advisable 
to  defer  its  separation  until  reposition  has  been  effected,  because  the  con- 
tractile function  of  the  inverted  uterus  being  in  abeyance  there  is  always 


732  OBSTETRICS 

the  risk  of  profuse  haemorrhage.  On  the  other  hand,  if  the  patient  is  not 
seen  until  well  advanced  in  the  puerperium.,  and  when  the  cervix  is  so  con- 
tracted that  reposition  cannot  be  accomplished  so  readily,  operative  pro- 
cedures become  necessary.  Full  particulars  concerning  these  will  be  found 
in  the  current  works  on  gynaecology. 

LITERATURE 

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Barxes.     The  Physiology  and  Treatment  of  Placenta  Praevia.     London,  1858. 

Placenta  Praevia.     Lectures  on  Obstetric  Operations,  4th  ed.     London,  1886,  398-422. 
Beckmanx.    Zur  Aetiologie  der  Inversio  uteri  post  partum.    Zeitschr.  f.  Geb.  u.  Gyn., 

1895,  xxxi,  371-401. 
Behm.     Die  combinirte  Wendung  bei  Placenta  praevia.     Zeitschr.  f.  Geb.  u.  Gyn.,  1883, 

ix,  373-419. 
Braun,  Chiari  und  Spaeth.     Paralyse  des  Uterus.     Klinik  der  Geb.  u.  Gyn.,  Erlangen, 

1855,  202-204. 
Browxe.     Inversion  of  the  Uterus.     Amer.  Gyn.  and  Obst.  Jour.,  1899,  xv,  115-129. 
Budix.     Hemorrhagies  uterin.es  et  rupture  du  sinus  cireulaire.     Femmes  en  couches  et 

nouveau  nes,  1897,  143-161. 
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Gyn.  Soc,  1891,  xvi,  35-50. 
Didry.     De  la  dilatation  manuelle  du  col  uterin  dans  les  accouchements  avec  hemorrha- 
gies placentaires  graves.     These  de  Nancy,  1899. 
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December  6,  1900,  cxliii,  571. 
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Klinik  in  Wien,  1897,  i,  77-119. 
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via.    N.  Y.  Med.  Jour.,  November  3,  1900. 
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January  12,  1902,  64-68. 
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1870,  ii,  281-346. 
Harris.     A  Method  of  performing  Rapid  Manual  Dilatation  of  the  Os  Uteri,  and  its 
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372. 
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599-607. 
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Tarxier  et  Budin.     Hemorrhagic    par   insertion  vicieuse  du  placenta.     Traite  de  l'art 

des  accouchements,  1898,  iii,  571-659. 
Veit.     Ueber  die  Behandlung  der  Blutungen  unmittelbar  nach  der  Geburt.     Zeitschr.  f. 

Geb.  u.  Gym,  1895,  xxxi,  214-225. 
Vogel.     Beitrag  zur  Lehre  von  der  Inversio  uteri.     Zeitschr.  f.  Geb.  u.  Gvn.,  1900,  xlii, 

490-525. 
W'ehle.     Ueber  Hamophilie  bei  einer  Gebarenden.     Centralbl.  f.  Gyn.,  1893,  672-675. 
Weiss.     Ueber  vorzeitige  Losung  der  normal  sitzenden  Placenta.     Archiv  f.  Gyn..  1897, 

xlvi,  256-291. 
Zur  Kasuistik  der  Placenta  praevia  centralis.     Centralbl.  f.  Gyn..  1897,  641-649. 
Winter.     Zur  Lehre  von  der  vorzeitigen  Placentarlosung  bei  Nephritis.     Zeitschr.  f.  Geb. 

u.  Gyn.,  1885,  xi,  398-408. 


CHAPTER    XLII 
INJURIES   TO    THE  BIRTH  CANAL 

Injuries  to  the  Vulval  Outlet. — In  the  chapter  upon  the  Conduct  of  Nor- 
mal Labour  reference  was  made  to  the  frequency  of  perineal  lacerations, 
and  emphasis  was  laid  upon  the  necessity  for  repairing  them  immediately 
after  the  birth  of  the  child. 

More  rarely  tears  occur  about  the  anterior  portion  of  the  vulva.  In 
spontaneous  labour  these  seldom  amount  to  more  than  slight  abrasions  upon 
the  inner  surfaces  of  the  labia  minora,  but  in  operative  deliveries,  espe- 
cially when  the  handles  of  the  forceps  have  been  unduly  elevated,  serious 
lesions  may  be  produced  as  a  result  of  compression  of  the  tissues  between 
the  pubic  arch  and  the  blades  of  the  instrument.  Now  and  again  the  labia 
minora  are  completely  severed  and  torn  loose  from  their  connections,  or 
deep  tears  occur  on  either  side  of  the  urethra  implicating  the  vessels  sup- 
plying the  clitoris  and  giving  rise  to  profuse  haemorrhage. 

Injuries  to  the  Vagina. — "With  the  exception  of  the  most  superficial  va- 
rieties, which  are  limited  to  the  mucous  membrane  of  the  fourchette,  all 
perineal  lacerations  are  accompanied  by  more  or  less  injury  to  the  lower 
portion  of  the  vagina.  Such  tears  rarely  occur  in  the  median  line,  but  ex- 
tend a  variable  distance  up  one  or  both  vaginal  sulci,  being  almost  always 
sufficiently  deep  to  involve  some  fibres  of  the  levator  ani  muscle.  Bilateral 
lacerations  of  this  variety  are  usually  unequal  in  length  and  are  separated 
from  one  another  by  a  tongue-shaped  portion  of  mucosa  which  represents 
the  lower  end  of  the  posterior  column  of  the  vagina  (Fig.  297). 

These  injuries  should  always  be  looked  for,  and  their  repair  should  form 
a  part  of  every  operation  for  the  restoration  of  a  lacerated,  perinaeum.  If 
this  precaution  is  neglected  and  the  external  wound  alone  is  attended  to, 
the  patient  will  eventually  present  symptoms  due  to  relaxation  of  the  vag- 
inal outlet,  even  though  the  perinaeum  proper  may  be  in  perfect  condition. 

Isolated  tears  involving  the  middle  third  of  the  vagina,  and  unasso- 
ciated  with  lacerations  of  the  perinaeum  or  cervix,  are  very  rarely  observed. 
They  are  usually  longitudinal,  and  result  from  injuries  sustained  during 
a  forceps  operation,  though  now  and  again  they  follow  spontaneous  deliv- 
ery. They  frequently  extend  deeply  into  the  underlying  tissues,  and  may 
give  rise  to  a  copious  haemorrhage,  which,  however,  is  readily  controlled 
by  a  few  sutures.  Their  presence  is  usually  overlooked,  inasmuch  as  they 
can  be  recognised  only  after  the  vaginal  walls  are  spread  apart  by  means 
of  a  speculum. 
734 


LWIt'KIKS   TO   THE    UlltTll    CANAL  Too 

More  important  are  the  injwieAjtOjh^  which  are  not 

associated  with  tears  through  the  vaginal  mucosa  and  therefore  escape 
immediate  detection.  As  the  result  of  overdistention  of  the  birth  canal, 
there  may  occur  a  submucous  separation  of  certain  fibres  of  the  muscle,  or  at 
least  so  great  a  diminution  in  its' tonicity  that  it  can  no  longer  properly 
fulfil  its  function  as  the  pelvic  diaphragm.  In  these  cases  the  patient 
sooner  or  later  suffers  just  as  severely  from  symptoms  of  relaxation  as  if 
a  deeply  lacerated  perinauun  had  been  left  unrepaired.  Although  the  acci- 
dent can  sometimes  be  avoided  by  an  intelligent  use  of  forceps  when  the 
second  stage  of  labour  is  unduly  prolonged,  indications  for  prophylactic 
measures  are  not  always  at  hand,  since  it  not  infrequently  follows  spontane- 
ous and  rapid  delivery. 

Lesions  of  the  upper  third  of  the  vagina  are  extremely  uncommon  un- 
less they  represent  the  extension  of  dee])  cervical  tears  into  the  fornix.  In 
very  rare  instances,  however,  the  cervix  may  be  entirely  or  partially  torn 
loose  from  its  vaginal  attachment,  rupture  in  other  cases  occurring  in 
either  the  anterior,  posterior,  or  lateral  fornix.  Hugenberger,  in  1875,  col- 
lected 40  cases  of  this  accident  from  the  literature,  and  designated  it  as 
colpaporrhexis.  Schtschotkin,  in  1891,  published  40  additional  instances, 
while  Kaufmann,  in  1901,  estimated  that  something  more  than  100  cases 
have  been  recorded  altogether. 

The  accident  is  somewhat  analogous  to  rupture  of  the  lower  uterine 
segment,  and  follows  energetic  efforts  on  the  part  of  the  uterus  to  over- 
come some  obstacle  to  the  passage  of  the  child.  As  a  result  of  the  re- 
traction of  Bandl's  ring,  so  great  a  strain  may  be  exerted  upon  the  ~c£cyix_ 
that  it  js_torn  loose  from  its  vaginal  attachment.  It  is  commonly  taught 
that  colpaporrhexis  is  possible  only  in  those  cases  in  which  the  lips 
of  the  cervix  are  not  compressed  between  the  presenting  part  and  the 
pelvic  wall,  but  are  free  to  follow  the  retracting  uterus.  It  sometimes 
occurs  spontaneously,  but  more  frequently  follows  ill-chosen  operative 
procedures. 

The  syxoMoms  are  identical  with  those  following  rujit^rre_pj_tli^jrtenis, 
and  will  be  considered  under  that  heading.  Immediately  following  the 
rupture,  the  child  may  escape  into  the  peritoneal  cavity,  after  which  the 
intestines  may  protrude  into  the  vaginal  canal,  as  in  a  case  reported  by 
Eoss. 

The  diagnosis  is  made  solely  by  the  sense  of  touch,  as  the  clinical  symp- 
toms do  not  differ  from  those  following  rupture  of  the  uterus.  The  prog- 
nosis is  extremely  unfavourable,  60  to_  75  per  cent  of  the  cases  reported  in 
the  literature  having  ended  fatally. 

Most  authorities  recommend  treating  the  condition  by  means  of  a  vag- 
inal pack,  a  procedure  which  probably  explains  in  part  the  high  mortality. 
Everke  recommends  repairing  the  rupture  through  the  vagina  after  extract- 
ing the  child.  I  am  inclined  to  agree  with  Schick  that  laparotomy  offers 
the  best  chance  for  successfully  coping  with  this  emergency,  since  in  this 
way  one  can  obtain  an  accurate  idea  of  the  extent  of  the  injury,  when  it 
may  sometimes  be  possible  to  unite  the  torn  surfaces  by  sutures,  or,  failing 
that,  to  remove  the  uterus. 


736  OBSTETRICS 

Lesions  of  the  Cervix. — Slight  degrees  of  cervical  laceration  must  be 
regarded  as  an  inevitable  accompaniment  of  childbirth.  Such  tears,  how- 
ever, heal  rapidly  and  rarely  give  rise  to  symptoms.  In  healing  they  cause 
a  material  change  in  the  shape  of  the  external  os,  and  thereby  afford  us  a 
means  of  determining  whether  a  woman  has  borne  children  or  not. 

In  other  cases  the  tears  are  deeper,  not  infrequently  implicating  one 
or  both  sides  of  the  cervix  and  extending  as  far  upward  as  the  vaginal 
junction.  In  rarer  instances  the  laceration  may  extend  across  the  vaginal 
fornix  or  into  the  lower  uterine  segment,  and  occasionally  open  up  the  base 
of  the  broad  ligament.  Such  extensive  lesions  usually  involve  vessels  of  con- 
siderable size,  and  are  nearly  always  associated  with  profuse  haemorrhage. 

Deep  cervical  tears  occasionally  occur  during  the  course  of  spontaneous 
labour,  and  under  such  circumstances  their  genesis  is  not  always  readily 
explainable.  More  usually,  however,  they  follow  attempts  at  rapid  manual 
or  instrumental  dilatation,  especially  in  eclampsia,  placenta  prEevia,  and  in 
women  suffering  from  general  oedema.  Moreover,  they  are  apt  to  result 
from  attempts  at  delivery  through  an  imperfectly  dilated  cervix^  no  matter 
whether  forceps  or  version  be  employed. 

Occasionally,  even  in  spontaneous  labours,  the  anterior  lip  of  the  cervix 
may  be  caught  between  the  head  and  the  symphysis  pubis  and  compressed 
until  it  undergoes  necrotic  changes  and  separation  occurs.  In  still  rarer 
instances  the  entire  vaginal  portion  may  be  torn  loose  from  the  rest  of  the 
cervix.  According  to  Boudreau,  this  so-called  circular  detachment  of  the 
cervix  usually  occurs  in  elderly  primiparae  when  the  pains  are  strong  and 
a  serious  obstacle  to  delivery  is  offered  by  an  imperfectly  dilated  os- 
externum. 

Symptoms. — In  all  lesions  involving  the  cervix  there  is  usually  no  escape 
of  blood  until  after  the  birth  of  the  child,  when  the  haemorrhage  may  be 
profuseT'  In  many  cas"es,  however,  the  bleeding  is  so  slight  that  the  con- 
dition would  pass  unrecognised  were  it  not  detected  upon  an  examination 
made  for  some  other  indication.  When  one  lip  of  the  entire  vaginal  por- 
tion of  the  cervix  is  torn  off  there  is  usually  very  little  haemorrhage,  for 
the  reason  that  the  tissues  have  been  so  compressed  before  the  occurrence 
of  the  accident  that  the  vessels  have  undergone  thrombosis;  likewise,  cir- 
cular detachment  of  the  cervix  is  often  not  followed  by  bleeding. 

Most  cervical  tears  heal  spontaneously,  provided  the  patient  remains- 
uninfected;  but  the  deep  wound  affords  to  any  pathogenic  micro-organisms 
which  may  be  present  a  ready  port  of  entry  into  the  lymphatics  at  the  base 
of  the  broad  ligament. 

Diagnosis. — A  deep  cervical  tear  should  always  be  suspected  in  cases 
of  profuse  haemorrhage  coming  on  during  the  third  stage  of  labour,  if  the 
hand  applied  over  the  lower  abdomen  can  feel  that  the  uterus  is  firmly 
contracted.  For  a  positive  diagnosis,  however,  a  vaginal  examination  is- 
necessary,  while  the  extent  of  the  injury  can  be  fully  appreciated  only 
after  drawing  the  cervix  down  to  the  vulva  and  subjecting  it  to  direct 
inspection. 

Tears  unaccompanied  by  haemorrhage  usually  escape  detection  unless 
they  are  accidentally  discovered  during  a  vaginal  examination  made  for 


IX.Il'KIKS   T(>   TI1K    HIItTII    CANAL 


737 


some  other  reason.  Annular  detachment  of  the  vaginal  portion  of  the 
cervix  should  be  diagnosed  whenever  an  in^ukr_mass  of  tissue  having 
a  circular  opening  is  cast  off  before  or  after  the  birth  of  the  child. 

Treatment. —  Deep  cervical  tears  accompanied  by  haemorrhage  should  be 
immediately  repaired,  the  introduction  of  a  few  sutures  readily  checking 
the  How  of  blood.  On  the  other  hand,  if  the  condition  is  not  associated 
with  haemorrhage,  it  is  advisable  to  leave  the  patient  alone  rather  than 
subject  her  to  the  manipulations  necessary  for  its  repair,  which  inevitably 
expose  her  to  additional  risks  of  infection.  Moreover,  in  the  majority  of 
such  tears  spontaneous  healing  ensues,  and  in  the  exceptional  cases  in  which 
this  does  not  occur,  better  results  are  usually  obtained  by  a  secondary  opera- 
tion performed  in  the  latter  part  of  the  puerperium. 

The  treatment  of  cervical  tears  associated  with  hasmorrhage  varies  with 
the  extent  of  the  lesion.     When  the  laceration  is  limited  to  the  cervix,  or 


Fig.  619. — Lacerated  Cervix  drawn  down  to  Vulva,  Preparatory  to  Repair  (Bumm), 

even  when  it  extends  well  into  the  vaginal  fornix,  most  satisfactory  results 
are  obtained  by  the  introduction  of  sutures  after  bringing  the  cervix  into 
view  at  the  vulva.  This  is  effected  by  having  an  assistant  make  firm  down- 
ward pressure  upon  the  uterus,  while  at  the  same  time  the  operator  exerts 
strong  traction  by  means  of  a  bullet  forceps  inserted  into  either  lip  of  the 
48 


738  OBSTETRICS 

cervix,  the  vaginal  walls,  if  necessary,  being  held  apart  by  means  of  suitable 
retractors  (Fig.  619).  As  the  haemorrhage  usually  comes  from  the  upper 
angle  of  the  wound,  it  is  advisable  to  apply  the  first  suture  in  this  situation, 
since  if  the  suturing  is  begun  at  the  free  end  of  the  tear,  a  dead  space  is 
often  left  towards  its  upper  end  from  which  subsequent  haemorrhage  may 
occur.  Either  silkworm  or  catgut  sutures  may  be  employed.  The  beginner 
is  cautioned  against  too  great  a  regard  for  appearances  and  attempting  to 
give  the  cervix  too  normal  a  look,  inasmuch  as  the  retraction  occurring 
within  the  next  few  days  may  lead  to  such  constriction  of  its  lumen  as  to 
cause  retention  of  the  lochial  discharge. 

Many  authorities  recommend  a  tight  vaginal  pack  in  this  class  of  eases. 
This  will  usually  check  the  haemorrhage  and  may  be  employed  in  an  emer- 
gency, but  its  employment  does  not  compare  in  efficiency  with  repair  by 
suture.  In  the  rare  cases  in  which  the  wound  extends  through  the  broad 
ligament  into  the  peritoneal  cavity,  a  tight  pack  may  be  introduced,  pro- 
vided there  is  no  serious  haemorrhage;  but  in  all  other  cases  the  only  satis- 
factory method  of  dealing  with  the  condition  is  by  laparotonry. 

The  treatment  of  tears  of  the  upper  part  of  the  cervix  which  involve 
the  lower  uterine  segment  will  be  considered  when  we  take  up  the  treatment 
of  rupture  of  the  uterus. 

Rupture  of  the  Uterus. — This  accident,  which  is  one  of  the  most  serious 
with  which  the  obstetrician  can  be  confronted,  seldom  occurs  except  in 
prolonged  labours,  although  instances  of  sj:>ontaneous  nature  during  preg- 
nancy are  on  record. 

(a)  During  Pregnancy. — Eeference  has  already  been  made  to  rupture 
which  occurs  during  the  course  of  gestation,  in  a  rudimentary  horn  of  a 
bicornuate  uterus  or  in  the  interstitial  portion  of  the  Fallopian  tube,  as  well 
as  to  the  exceptional  cases  in  which  the  iiterine  scar  following  Caesarean 
section  gives  way  in  a  subsequent  pregnancy,  and  its  mode  of  production 
is  readily  understood. 

On  the  other  hand,  the  serological  factors  concerned  in  spontaneous  rup- 
ture of  the  apparently  normal  pregnant  uterus  are  not  so  readily  explained, 
many  causes  having  been  invoked,  but  none  are  of  universal  application. 
Thus,  in  some  instances,  the  accident  may  be  attributed  to  faulty  hypertro- 
phy of  the  uterine  wall  in  the  fundal  region.  Alexandroff,  JeTTinghaus,  ancT 
'others- are  Inclined  to  attribute  certain  cases  to  inherent  weakness  of  the 
uterine  walls  resulting  from  the  excessive  formation  of  connective  tissue  fol- 
lowing the  manual  removal  of  an  adherent  placenta  in  previous  pregnancies. 
Herzfeld  holds  that  in  one  of  his  cases  the  accident  was  due  to  anatomical 
changes  following  curettage  in  a  previous  pregnancy.  Poroschin  considers 
that  he  was  able  to  demonstrate  in  certain  cases  a  faulty  development  or 
relative  absence  of  the  elastic-tissue  fibres  which  are  normally  present  in  the 
uterine  walls.  All  the  possibilities  which  have  been  suggested  in  this  con- 
nection have  been  considered  in  detail  by  Sanger,  and  while  some  of  them 
are  applicable  to  a  certain  number  of  cases,  it  is  impossible  to  offer  a  satis- 
factory explanation  for  others.  Blind,  after  the  study  of  22  cases  reported 
in  the  literature,  states  that  the  rupture  nearly  always  occurs  in  the  upper 
part  of  the  uterus,  usually  in  the  neighbourhood  ofThe  fundus. 


INJURIES  TO  THE   BIRTH   CANAL  739 

The  symptoms,  diagnosis,  prognosis,  and  treatment  of  this  condition 
are  identical  with  those  following  rupture  Of  the  uterus  occurring  at  the 
time  of  labour.  It  should  be  noted,  however,  that  in  a  number  of  the  cases 
reported  in  the  literature  the  haemorrhage  following  the  accidenl  v.. 
slighl  as  not  to  give  rise  to  symptoms,  the  condition  escaping  recognition 
until  operative  procedures  became  necessary  for  the  removal  of  the  foetus 
lying  free  in  the  abdominal  cavity. 

In  several  instances,  as  in  the  cases  reported  by  Leopold  and  Ilenrotin, 
the  placenta  remained  in  the  uterus,  while  the  foetus,  surrounded  by  its 
membranes;  escaped  into  the  peritoneal  cavity,  where  it  went  on  to  further 
development — utero-abdominal  pregnancy.  Such  an  occurrence  is  very  ex- 
ceptional, a~s  it  is  usually  synonymous  with  foetal  death. 

(b)  Rupture  of  the  Uterus  at  the  Time  of  Labour. — Tins  not  very  infre- 
quent accident  is  one  of  the  most  serious  complications  of  labour,  as  it 
nearly  always  leads  to  the  death  of  the  foetus,  and  frequently  to  that  of  the 
mother  as  well. 

Mtiohgy. — Practically  we  are  indebted  to  Bandl  for  the  first  clear  ex- 
planation as  to  the  mode  of  its  production,  its  aetiology  being  inseparably 
connected  with  the  doctrine  of  the  lower  uterine  segment  and  the  forma- 
tion of  the  contraction  ring. 

Normally,  under  the  influence  of  labour  pains  the  uterus  becomes  dif- 
ferentiated into  two  portions,  separated  by  a  circular  ridge  of  tissue,  to 
which  the  term  eon  tract  ion  ring  is  usually  applied.  The  upper,  by  its  con- 
tractions, seiwes  to  expel  the  child,  while  the  lower  undergoes  dilatation 
and  merely  forms  part  of  the  canal  through  which  the  contents  of  the 
uterus  are  forced.  On  the  other  hand,  when  a  serious  obstacle  is  opposed 
to  the  passage  of  the  child,  the  actiye  portion  of  the  uterus  is  stimulated 
to  more  forcible  efforts.  As  it  contracts  it  likewise  slowly  becomes  re- 
tracted, its  lower  margin — the  contraction  ring — eyentually  occupying  a 
much  higher  leyel  than  usual.  As  a  result,  particularly  if  the  lips  of 
the  ceryix  are  caught  between  the  presenting  part  and  the  superior  strait, 
powerful  upward  traction  is  exerted  upon  the  passive  portion  of  the  uterus, 
which  becomes  more  and  more  stretched,  and  thinner  and  thinner.  At  the 
same  time  the  contraction  ring  separating  the  two  portions  becomes  thicker 
and  more  prominent,  so  that  it  can  readily  be  distinguished  as  a  transyerse 
or  oblique  ridge  extending  across  the  abdomen  just  below  or  perhaps  on  a 
leyel  with  the  umbilicus.  The  round  ligaments,  likewise,  are  subjected 
to  an  abnormal  strain  and  remain  tense  even  in  the  intervals  between  the 
uterine  contractions. 

As  the  process  goes  on  the  lower  segment  becomes  extremely  sensitiye 
to  pressure,  the  uterine  contractions  increase  progressiyely  in  frequency 
and  intensity,  and  cause  the  patient  greater  suffering.  The  pulse  becomes 
more  rapid,  and  the  patient  presents  a  worn  and  haggard  appearance.  Such 
a  condition  indicates  that  rupture  is  imminent  and  will  occur  unless  deliyery 
is  promptly  effected  in  a  conseryatiye  manner. 

Generally  speaking,  rupture  is  more  apt  to  take  place  when  one  side  of 
the  lower  uiej^ne^e^Tiient  is  subjected  to  greater  stretching  than  the  other. 
In  transyerse  presentations  this  condition  is  most  marked  on  the  side  of 


740  OBSTETRICS 

the  uterus  ocfiupiedjay  fhp  heap  A  similar  danger  threatens  the  posterior 
wall  when  the  child  presents  by  the  head  and  the  patient  has  a  markedly 
pendulous  abdomen. 

Excessive  stretching  of  the  lower  uterine  segment,  and  consequent 
danger  of  rupture,  is  favoured  by  any  factor  which  interferes  with  the 
birth  of  the  child,  and  more  particularly  with  the  entrance  of  the  presenting 
part  into  the  pelvis.  Such  conditions  are  most  frequently  afforded  by  con- 
tracted pelves,  neglected  transverse  presentations,  hydrocephalus,  excessive 
size  of  the  child,  and,  in  fact,  by  any  obstacle  to  labour.  The  following 
analysis  by  Merz  shows  the  aetiological  factors  concerned  in  the  production 
of  160  cases  of  rupture  of  the  uterus: 

Contracted  pelvis 70 

Neglected  transverse  presentation 26 

Hydrocephalus 18 

Large  child  or  unfavourable  presentation 10 

Stenosis  of  birth  canal 6 

Trauma 5 

Pelvic  tumour 3 

Ascites 1 

Operative  procedures 21 

It  is  customary  to  distinguish  between  spontaneous  and  violent  rupture 
of  the  uterus.  In  the  former  the  accident  occurs  spontaneously,  while  in 
the  latter  it  is  usually  the  result  of  ill-judged  manipulations  on  the  part 
of  the  obstetrician  in  a  uterus  whose  lower  segment  is  so  thinned  out  and 
distended  that  the  slightest  violence  proves  too  much  for  its  resistive 
powers. 

Violent  rupture  occurs  relatively  frequently  when  version  is  attempted 
in  neglected  transverse  presentations.  The  proper  treatment  of  this  class 
of  cases  requires  the  utmost  nicety  of  judgment,  as  it  is  ofttimes  extremely 
difficult  to  determine  whether  the  lower  uterine  segment  is  so  thinned  out  as 
to  contra-indicate  attempts  at  version,  the  operation  having  been  readily  ac- 
complished under  anaesthesia  in  some  cases  in  which,  at  first  sight,  it  had 
appeared  impracticable;  whereas  in  others,  in  which  it  seemed  that  the  neces- 
sary manipulations  would  be  without  danger,  rupture  followed  the  mere 
introduction  of  the  hand.  Moreover,  there  is  a  marked  difference  in  the 
rapidity  with  which  overstretching  of  the  lower  uterine  segment  comes 
about,  the  condition  supervening  very  rapidly  in  some  cases,  while  in 
others  many  hours  of  strong,  second-stage  pains  may  be  necessary  for  its 
production. 

Certain  women  seem  to  possess  a  predisposition  towards  rupture  of  the 
uterus,  this  assumption  being  supported  by  the  fact  that  not  a  few  cases 
of  repeated  rupture  appear  in  the  literature.  Thus,  Mikhine  found  records 
of  13  patients,  6  of  whom  died  as  a  result  of  a  second  rupture,  and  Peham 
has  likewise  reported  similar  instances.  It  is  quite  likely  that  under  such 
circumstances  the  second  rupture  occurs  in  tissues  already  weakened  by  the 
previous  accident. 

Pathology. — Rupture  of  the  uterus  occurring  at  the  time  of  labour  is 
limited  almost  entirely  to  the  lower  uterine  segment,  the  rent  usually  pur- 


INJURIES  TO   THE    BIRTH   CANAL 


741 


suing  an  oblique  direction;  although  when  it  is  in  the  immediate  vicinity 
of  the  cervix  it  frequently  extends  transversely.  On  the  other  hand, 
it  is  usually  longitudinal  when  it  occurs  in  the  portion  of  the  uterus 
adjacent  to  the  broad  ligament. 

It  is  customary  to  distinguish  between  c ojn pi e I e  and  i>\cojjij>leie_riipiure. 
according  as  the  laceration  communicates  directly  with  the  peritoneal  cav- 
ity or  is  separated  from  it  by  the  perineal  covering  of  the  uterus  or  broad 
ligament.  The  former  is  apparently  the  more  common,  Merz  having  col- 
lected 118  complete  as  against  -16  incomplete  ruptures.  Koblanck  noted 
58  and  2-1  respectively  in  80  cases  occurring  in  the  Berlin  Frauenklinik. 

Incomplete  ruptures  not  infrequently  extend  into  the  broad  ligament; 
under  such  circumstances  the  haemorrhage  often  occurs_  less  rapidly  than 


Fig.  620. — Longitudinal  Section  through  "Woman  Dying  from  Eupture  of  the  Uterus 

(Zweifel). 

in  the  complete  variety,  the  blood  slowly  accumulating  between  the  leaflets 
and  leading  to  the  separation  of  the  peritonaeum  from  the  surrounding 
viscera,  with  the  consequent  formation  of  a  large  subperitoneal  Jicematoma. 
Occasionally,  a  haemorrhage  sufficiently  copious  to  cause  the  death  of  the 
patient  may  remain  inclosed  between  the  structures.  More  frequently, 
however,  the  fatal  issue  does  not  occur  until  rupture  of  the  haematoma  into  ) 
the  peritoneal  cavity  relieves  the  pressure  which  had  previously,  to  some  j 
extent,  restrained  the  bleeding. 

Although  the  rupture  occurs  primarily  in  the  lower  uterine  segment, 
it  is  not  unusual  for  the  laceration  to  extend  further  upward  into  the  body 
of  the  uterus  or  downward  through  the  cervix  into  the  vagina,  primary 
lesions  of  the  uterine  body,  as  a  rule,  being  observed  only  in  the  cases 
of  spontaneous  rupture  occurring  during  pregnancy.  The  tear  itself  usually 
presents  jagged,  irregular  margins  which  are  stained  with  blood. 

Following  complete  rupture,  the  uterine  contents  may  escape  into  the 
peritoneal  cavity,  while  in  the  incomplete  variety  they  may  come  to  lie 


742  OBSTETRICS 

beneath  the  serous  covering  of  the  uterus  or  between  the  leaflets  of  the 
broad  ligament.  In  a  certain  number  of  cases  of  either  variety,  however, 
particularly  when  the  presenting  part  is  firmly  engaged  at  the  time  of  rup- 
ture, only  a  portion  of  the  foetus  escapes,  the  rest  remaining  in  the  uterine 
cavity. 

Symptoms. — The  symptoms  of  actual  rupture  vary  considerably.  As  a 
rule,  the  patient,  after  presenting  for  some  time  the  premonitory  signs  of 
the  accident,  suddenly,  at  the  height  of  an_ intense  uterine  contraction 
or  during  an  intra-uteidn\jnanipulation.  complains  of  a  sliarp\  shooting 
pain  in  the  lower  abdomen,  and  frequently  cries  out  that  something  has 
given  way  inside  of  her.  At  the  same  time  the  lower  uterine_s_egmejit-he- 
comes  much  more  sensitive_to  pressure.  Immediately  following  these  symp- 
toms there  is  an  absolute  cessation  of  the  uterine  contractions,  and  the 
patient,  who  has  previously  been  m  intense  agony,  suddenly  experiences 
marked  ivlu^.  At  the  sanir  time  there  is  usually  more  or  Less  external 
hemorrhage,  though  not  uncommonly  it  is  very  slight  in  amount. 

Palpation  or  vaginal  examination  shows  that  the  presenting  part  has 
slipped  away  from  the  superior  strait_and  has  become  movable,  while  a  hard, 
round  body,  which  represents  the  firmly  contracted  uterus,  can  be  felt 
alongsidg_of  the  foetus.  Naturally,  if  the  uterine  contents  have  escaped 
into  the  abdominal  cavity,  the  presenting_p,art^cannot  be  felt  on  vaginal 
examination. 

As  a  rule,  shortly  after  the  occurrence  of  complete  rupture,  the  patient 
presents  symptoms  of  collapse^  the  pulse_  increases  markedly  in  rapidity, 
lnsps  tone.,  and  takes  on  a  filiform  character,  the  face  becomes  pallid,  assumes 
a  drawn  appearance,  and  is  often  covered  withbeads  of  sweat.  If  the 
haemorrhage  has  been  copious,  she  may  complain  of  clullinsas^  disturbances 
of  vision,  and  airjiunger,  and  eventually  pass  into  an  unconscious  state. 

Symptoms  of  collapse,  however,  do  not  always  appear  immediately,"  but 
are  sometimes  deferred  for  several  hours  after  rupture,  being  less  marked 
when  the  child  remains  partially  within  the  uterus.  After  incomplete 
rupture,  on  the  other  hand,  the  immediate  symptoms  are  sometimes  very 
slight,  but  increase  in  severity  as  the  subperitoneal  hsematoma  becomes 
larger,  while  actual  symptoms  of  collapse  frequently  do  not  appear  until 
secondary  rupture  into  the  peritoneal  cavity  has  taken  place. 

In  a  certain  number  of  cases  of  incomplete  rupture,  emphysematous 
crackling  can  be  elicited  in  the  tissues  of  the  anterior  abdominal  wall,  14 
cases  6T"this  character  having  been  collected  by  Dischler.  It  would  appear 
probable  that  the  condition  is  usually  due  to  the  invasion  of  the  subperi- 
toneal connective  tissue  by  Bacillus  aerogenes  capsulatus.  It  is  true  that 
bacteriological  proof  has  not  been  adduced  in  support  of  this  statement, 
but  the  fact  that  the  women  had  been  in  labour  for  many  hours,  and  that 
many  of  the  children  were  more  or  less  putrefied,  speaks  strongly  in  favour 
of  such  a  view. 

Diagnosis. — The  diagnosis  is  usually  easy,  especially  in  the  cases  in 
which  the  accident  occurs  while  the  patient  is  under  supervision.  If  she  is 
not  seen  until  later,  the  characteristic  history  and  the  cojjanse  are  almost 
pathognomonic,  the  only  other  conditions  in  which  the  latter  is  noted 


INJURIES  TO  THK   BIRTB   CANAL  743 

before  delivery  being  the  eases  <>!'  haemorrhage  following  the  rupture  of 
an  advanced  extra-uterine  pregnancy,  or  the  premature  separation  of  tin.' 
normally  implanted  placenta. 

11'  the  child  has  escaped  into  the  abdominal  cavity,  it  is  much  more 
readilv  fell  on  palpation  than  usual,  while  on  one  side  of  it  the  hard, 
rounded  body  of  the  uterus  can  he  detected.  .Moreover,  vaginal  examina- 
tion frequently  reveals  the  existence  of  a  tear  in  the  uterine  wall  through 
which  the  fingers  can  be  passed  into  the  abdominal  cavity,  where  they  come 
in  contact  with  the  intestines.  Again,  the  fact  that  the  presenting  part 
cannot  be  felt  is  conclusive  evidence  that  the  foetus  has  escaped  from  the 
uterus. 

Prognosis. — The  chances  for  the  child  are  almost  uniformly  bad,  since 
it  frequently  succumbs  before  the  occurrence  of  the  accident.  On  the 
other  hand,  if  it  has  survived  up  to  that  time,  its  only  chance  of  living  is 
afforded  by  immediate  extraction,  asphyxia,  the  result  of  the  separation 
of  the  placenta,  being  otherwise  inevitable.  If  left  to  themselves,  the  vast 
majority  of  themothers  diefrom  haemorrhage  or  infection,  although  spon- 
taneous recover}"  has"  been  noted  in  exceptional  cases. 

Dpqth  from  hauriorrha.o-e  usually  occurs  within  the  first  few  hours, 
though  occasionally  it  may  be  deferred  for  forty-eight  hours;  in  infection 
the  fatal  termination  does  not  occur  for  some  days. 

Spontaneous  recovery  is  least  likely  to  occur  when  the  child  has  escaped 
into  the  abdominal  cavity,  though  isolated  instances  are  on  record  in  which 
the  patient  has  survived  even  such  an  accident.  Under  such  circumstances 
the  child  dies,  and  may  then  undergo  any  one  of  the  several  eventualities 
mentioned  in  the  chapter  on  Extrauterine  Pregnancy.  So  far  as  the 
women  are  concerned,  even  if  they  are  properly  treated,  the  mortality  is 
very  high,  at  least  one  third  succumbing. 

Treatment. — (a)  Prophylactic. — Intelligent  care  of  the  lying-in  woman 
should  almost  entirely  do  away  with  this  accident.  "Whenever  there  is  a 
possibility  of  the"  existence  of  an  obstacle  to  the  birth  of  the  child,  the  ob- 
stetrician should  always  be  on  the  alert  for  symptoms  indicative  of  impend- 
ing rupture.  Transverse  presentations  should  be  promptly  delivered  by 
version  as  soon  as  the  cervix  is  fully  dilated;  in  head  presentations  failure 
of  engagement  after  one  hour  of  strong  second-stage  pains  should  be  re- 
garded with  suspicion,  and  if  the  contraction  ring  rises  up  labour  should 
be  promptly  terminated  by  the  most  conservative  procedure.  In  neglected 
cases,  decapitation  in  transverse  and  craniotomy  in  head  presentations  often 
promise  the  best  results.  Such  procedures  are  the  more  justifiable  under 
the  circumstances,  as  the  children  are  usually  either  already  dead  or  ex- 
posed to  such  danger  that  their  chances  of  being  delivered  alive  are 
very  slight. 

(b)  Curative. — If  the  child  is  still  within  the  uterus,  delivery  should  be 
promptly  effected  by  the  natural  passages  in  the  most  conservative  manner 
possible.  On  the  other  hand,  if  it  has  already  escaped  into  the  abdominal 
cavity,  laparotomy  should  be  performed,  and  followed,  after  removal  of  the 
child,  by  whatever  operative  procedures  may  be  deemed  necessary — su£ure^ 
of  the  tear,  supravaginal  amputation,  or  total  removal  of_the  uterus. 


744:  OBSTETRICS 

On  the  other  hand,  in  the  cases  which  are  not  seen  until  the  child  has 
already  been  delivered  per  vaginam,  and  in  which  the  uterine  rupture  was 
not  recognised  until  after  its  birth,  various  procedures  have  been  suggested 
by  different  authorities. 

Personally,  I  believe  that  the  best  results  will  follow  laparotomy,  no 
matter  what  the  character  of  the  tear  or  whether  the  patient  is  suffering 
from  haemorrhage  or  not,  for  the  reason  that  it  is  ofttimes  difficult  to  de- 
termine the  extent  of  the  laceration,  and  that  it  is  absolutely  impossible  to 
foretell  whether  the  haemorrhage  can  be  checked  by  simple  procedures;  and, 
even  if  these  succeed,  whether  the  result  will  be  permanent.  Fritsch  is 
correct  in  stating  that  the  only  method  by  which  we  can  assure  ourselves 
against  all  further  risk  of  haemorrhage  is  by  opening  the  abdomen.  Varnier 
takes  a  similar  view  as  the  result  of  his  experience  in  23  cases,  and  holds 
that  laparotomy  should  be  resorted  to  Avhenever  practicable. 

On  the  other  hand,  certain  authorities  argue  that,  inasmuch  as  the  danger 
to  be  apprehended  in  incomplete  rupture  is  from  haemorrhage  rather  than 
sepsis,  laparotomy  should  be  performed  only  in  those  cases  in  which  the 
loss  of  blood  is  profuse,  and  that  in  all  others  equally  good  if  not  better 
results  may  be  obtained  by  draining  or  packing  the  rupture  from  the 
vagina.  Such  a  procedure,  however,  would  not  appear  rational,  for  not 
infrequently  women,  who  are  apparently  in  excellent  condition  shortly  after 
the  occurrence  of  the  rupture,  begin  to  bleed  profusely  some  hours  later, 
and  are  then  in  danger  of  dying  before  operative  procedures  can  be  car- 
ried out. 

Schmit  reports  83  cases  treated  by  packing  or  drainage,  and  32  by  lapa- 
rotomy, with  a  mortality  of  48  and  75  per  cent  respectively;  while  Klien 
has  collected  a  series  of  125  and  149  cases,  with  a  respective  mortality  of 
39  and  44  per  cent.  The  latter  states  that  the  mortality  was  only  17  per 
cent  in  the  cases  which  were  treated  exclusively  by  drainage.  He  there- 
fore concludes  that  laparotomy  is  justifiable  only  in  those  cases  in  which 
haemorrhage  is  persistent  and  cannot  be  checked  by  other  measures.  Var- 
nier, on  the  contrary,  states  that  out  of  11  cases  in  his  experience  which 
were  treated  by  packing,  10  died;  whereas  3  of  the  6  patients  operated  upon 
recovered,  6  others  dying  before  operative  procedures  could  be  instituted. 
The  statistics  thus  far  adduced  can  hardly  be  regarded  as  conclusive,  inas- 
much as  it  is  probable  that  many  of  the  cases  were  seen  and  operated  upon 
only  as  a  last  resort. 

Instrumental  Perforation  of  the  Uterus. — Reference  has  already  been 
made  to  perforation  of  the  uterus  following  attempts  at  criminal  abortion 
or  in  the  effort  to  remove  placental  tissue  by  means  of  the  curette  or  poly- 
pus forceps,  after  an  incomplete  abortion.  Similar  accidents  likewise  occa- 
sionally occur  as  the  result  of  want  of  skill  on  the  part  of  the  obstetrician 
in  full-term  labour.  As  has  already  been  pointed  out,  not  infrequently, 
in  cases  of  this  character,  loops  of  intestine  prolapse  through  the  rupture. 
Under  such  circumstances  laparotomy  is  the  ideal  treatment,  though  in 
the  absence  of  prolapse  of  the  intestines  cases  are  recorded  in  which  re- 
covery occurred  spontaneously  under  what  were  apparently  most  unfavour- 
able circumstances. 


INJURIES   TO   THE    BIRTH    CANAL  745 

Perforation  of  the  Genital  Tract  following  Necrosis. — In  obstructed 
labour  the  tissues  in  various  portions  of  the  genital  trad  may  be  forcibly 
compressed  between  the  head  ami  the  bony  canal.  If  the  pressure  is  transi- 
tory it  is  without  significance;  bul  if  it  is  Long  continued,  necrosis  results, 
and  alter  a  few  days  the  area  implicated  sloughs  away  so  that  perforation 
follows. 

In  most  eases  of  this  character  the  perforation  occurs  between  the 
Vagina  and  the  bladder,  giving  rise  to  a  vesico-vaginal  fistula.  Less  fre- 
quently the  anterior  lip  of  the  cervix  is  compressed  against  the  symphysis 
pubis,  and  an  abnormal  communication  is  eventually  established  between 
the  cervical  canal  and  the  bladder — cervico-vesical  fistula. 

If  the  patient  is  not  infected,  the  fistulous  tract  frequently  heals  with- 
out further  treatment.  In  other  cases,  however,  it  may  persist,  when  a 
subsequent  plastic  operation  becomes  necessary  for  its  cure. 

Occasionally,  the  posterior  wall  of  the  uterus  may  be  subjected  to  so 
much  pressure  against  the  promontory  of  the  sacrum  that  necrosis  results, 
and  a  connection  is  established  with  Douglas's  cul-de-sac.  If  infection 
occurs,  the  accident  is  usually  followed  by  septic  peritonitis.  Fortunately, 
recovery  usually  follows  without  further  complications,  inasmuch  as  a  local- 
ized peritonitis  leads  to  the  formation  of  adhesions  between  the  posterior 
wall  of  the  uterus  and  the  pelvic  peritonaeum,  thereby  doing  away  with 
the  possibility  of  a  general  peritoneal  infection.  It  should  be  remembered 
that  similar  lesions  may  occur  in  the  rare  cases  in  which  exostoses  or 
bony  spicules  protrude  from  the  walls  of  the  birth  canal,  as  in  pelvis 
spinosa. 

LITERATURE 

Alexaxdroff.     Em  Fall  von  Uterusruptur  wahrend  der  Sehwangerschaft.     Honatsschr. 

f.  Geb.  u.  Gyn.,  1900,  xii,  447-457. 
Baxdl.     Ueber  Ruptur  des  Uterus  und  ihre  ATechanik.     Wien,  1875. 
Blixd.      Beitrag  zur  Aetiologie  der  Uterusruptur  wahrend  der  Sehwangerschaft  und 

unter  der  Geburt.     D.  I.,  Strassburg,  1892, 
Boudreau.     L'arrachement  circulaire  du  col  nterin  pendant  raccouchement.     These  de 

Toulouse,  1902. 
Dischler.      Ueber  subperitoneales   Emphysem  naeh   Ruptura  uteri.      Archiv  f.   Gyn., 

1898,  lvi.  199-217. 
Everke.     Ueber  Kolpaporrhexis  in  der  Geburt.     Monatsschr.  f.  Geb.  u.  Gyn.  1898,  vii, 

233-239. 
Fritsch.     Ueber  die  Behandlung  der  Uterusruptur.     Verh.  d.  deutschen  Gesell.  f.  Gyn., 

1895.  1-19. 
HeXrotix.     Utero-abdominal  Gestation.    The  Practice  of  Obstetrics  by  American  Authors, 

1890.  3S6. 
Herzfeld.     Ruptur  des  schwangeren  L'terus.     Centralbl.  f.  Gyn.,  1901,  1219-1227. 
Hugexberger.      Ueber  Kolpaporrhexis  in  der  Geburt.     Petersburger  med.   Zeitschr., 

1875,  v,  Heft  5,  26. 
Jellixghaus.     L^eber  Uterusrupturen  wahrend  der  Sehwangerschaft.     Archiv  f.  Gyn., 

1897,  liv,  103-116. 
Kaufmann.     Ueber  die  Zerreissung  des  Scheidengewolbes  wahrend  der  Geburt.     Monats- 
schr. f.  Geb.  u.  Gyn.,  1901.  xiii.  464-470. 


746  OBSTETRICS 

Klien.     Die  operative  unci  nicht  operative  Behandlung  der  Uterusruptur.     Archiv  f. 

Gyn.,  1900,  lxii,  Heft  2. 
Koblaxck.     Beitrag  zur  Lehre  von  der  Ruptura  uteri.     Stuttgart,  1895. 
Leopold.     Ausgetragene  secundare  Abdominalschwangerschaft  nach  Ruptura  uteri  trau- 
matica, etc.     Archiv  f.  Gyn.,  1896,  lii,  376-388. 
Herz.     Zur  Behandlung  der  Uterusruptur.     Archiv  f.  Gyn.,  1894,  xlv,  181-271. 
Mikhixe.     Un  cas  de  recidive  de  rupture  uterine.     Annales  de  Gyn.  et  d'Obst.,  1902,  Ivii, 

403-410. 
Peham.     Ueber  Uterusrupturen  in  Narben.     Centralbl.  f.  Gyn.,  1902,  87-94. 
Poroschin.     Zur  Aetiologie  der  spontanen  Uterusruptur  wahrend  Schwangerschaft  und 

Geburt.    Centralbl.  f.  Gyn.,  1898,  183. 
Ross.     Lacerated  and  Punctured  Wounds  of  the  Genital  Tract.     Amer.  Jour.  Obst,,  1898, 

xxxvii,  449-469. 
Sanger.     Ruptura  uteri.     Verb.,  der  deutschen  Gesell.  f.  Gyn.,  1895,  19-86. 
Schick.     Zerreissung  des  Scheidengewolbes  wahrend  der  Geburt,     Prager  med.  Wochen- 

schr.,  1893,  Nr.  29-30. 
Schmit.     Ein  Beitrag  zur  Therapie  der  Uterusruptur.     Monatsschr.  f.  Geb.  u..Gyn.,  1900, 

xii,  325-342. 
Schtschotkix.     Quoted  by  Kaufmann. 
Varnier,     Du  traitement  des  ruiatures  de  Tuterus.     Annales  de  Gyn.  et  d'Obst.,  1901, 

lvi,  249-279. 


CHAPTEE    XLIII 

PROLAPSE    OF    THE    UMBILICAL    CORD— ASPHYXIA    NEONATORUM 
—SUDD EX  DEATH  DURING   LABOUR 

Prolapse  of  the  Umbilical  Cord. — It  is  customary  to  distinguish  between 
presentation  and  prolapse  of  the  funis  or  umbilical  cord.  In  the  former  the 
cord  can  be  palpated  through  the  intact  membranes,  while  in  the  latter  a 
loop  of  it  protrudes  through  the  cervix  into  the  vagina,  and  exceptionally 
emerges  from  the  vulva. 

/Etiology. — In  general  it  may  be  said  that  any  factor  which  interferes 
with  the  accurate  adaptation  of  the  presenting  part  to  the  lower  uterine 
segment  predisposes  to  prolapse  of  the  cord.  Accordingly,  the  accident 
occurs  most  commonly  in  tr^nsyerje__ancLJoot,  and  less  often  in  frank 
breech  presentations.  On  the  other  hand,  it  is  rarely  observed  when  the 
child  presents  by  the  head,  unless  accommodation  is  interfered  with  as  a 
result  of  a  contractedjjelvis,  excessive  development  of  the  foetus,  hydram- 
niosL  or  abnormalfljiccjZity  of  the  lowjrjrterine  segment.  For  this  reason 
it  is  much  more  common  in  multiparous  than  in  primiparous  women. 

Symptoms. — Prolapse  of  the  cord  is  without  appreciable  effect  upon  the 
course  of  labour  so  far  as  the  mother  is  concerned.  On  the  other  hand, 
it  is  one  of  the  most  frecpient  causes  of  fcetal  death,  compression  between 
the  presenting  part  and  the  pelvic  wall  interfering  with  the  circulation 
to  such  an  extent  that  asphyxia  and  inevitable  death  often  follow  unless 
prompt  delivery  is  effected.  The  danger  is  greater  in  vertex  than  in  other 
presentations,  for  the  reason  that  there  is  less  likelihood  that  the  cord 
will  escape  compression  when  the  pelvic  canal  is  filled  oitt  by  the  hard, 
rounded  head  than  by  the  softer  and  more  irregularly  shaped  part  in  other 
presentations. 

Diagnosis. — Presentation  of  the  funis  is  diagnosed  when  on  palpation  a 
soft,  pulsating  cord-like  body  can  be  felt  through  the  membranes.  In  many 
instances,  however,  its  recognition  is  only  possible  when  the  cord  is  in  direct 
contact  with  the  presenting  part. 

Prolapse  of  the  cord,  on  the  other  hand,  is  readily  recognised,  since 
on  vaginal  examination  the  fingers  come  directly  in  contact  with  a  loop, 
while  exceptionally  the  structure  may  protrude  from  the  vulva.  Mistakes 
are  hardly  possible  if  the  foetus  is  alive,  as  distinct  pulsations  are  felt, 
although  in  their  absence  the  condition  is  sometimes  overlooked  on  super- 
ficial examination. 

The  possibility  of  prolapse  of  the  cord  should  be  particularly  borne  in 


748  OBSTETRICS 

mind  in  multiparous  women  in  whom  the  membranes  rupture  while  the 
head  is  still  freely  movable  above  the  superior  strait.  In  such  cases  the 
sudden  cessation  of  the  foetal  heart-beat  renders  the  diagnosis  almost  cer- 
tain, even  without  vaginal  examination. 

Treatment. — The  treatment  to  be  pursued  in  any  given  case  depends 
mainly  upon  the  degree  to  which  the  cervix  is  dilated,  and  to  a  lesser  ex- 
tent upon  the  presentation.  So  long  as  the  membranes  remain  intact  there 
is  no  immediate  danger  of  compression,  and  for  this  reason  every  precaution 
should  be  taken  to  avoid  their  premature  rupture,  vaginal  examinations 
being  made  with  the  utmost  gentleness.  At  the  same  time  the  obstetri- 
cian should  hold  himself  in  readiness  to  effect  delivery  as  soon  as  the 
cervix  is  sufficiently  dilated. 

If  the  membranes  have  already  ruptured,  provided  dilatation  is  com- 
plete and  the  child  presents  by  the  head,  its  life  can  often  be  saved  by 
prompt  delivery,  which  can  usually  be  effected  more  rapidly  by  version 
than  by  forceps,  unless  the  head  is  already  deep  down  in  the  pelvic  canal. 
In  breech  presentations,  a  foot  should  be  brought  down  and  followed  imme- 
diately by  extraction.     In  transverse  presentations  version  is  indicated. 

On  the  other  hand,  when  the  cervix  is  only  partially  dilated,  the  chances 
of  a  favourable  outcome  for  the  child  are  markedly  diminished.  If  the 
head  is  not  deeply  engaged  the  patient  should  be  placed  in  the  knee-chest 
position,  the  entire  hand  introduced  into  the  vagina,  and  an  attempt  made 
to  push  the  cord  up  into  the  uterus  and,  if  possible,  to  carry  it  over 
some  projecting  portion  of  the  child's  body.  If  the  cord  remains  in  the 
uterus  the  patient  should  be  made  to  lie  upon  the  side  towards  which  the 
child's  back  is  directed  in  the  hope  of  avoiding  compression. 

In  the  majority  of  cases,  however,  the  prolapse  recurs  again  as  soon  as 
the  hand  is  removed.  Under  such  circumstances  an  improvised  repositor 
will  sometimes  serve  us  in  good  stead,  although  the  results  attending  the 
use  of  such  devices  are  often  unsatisfactory.  A  piece  of  bobbin  is  firmly 
attached  to  the  free  end  of  a  sterile  bougie  or  catheter  in  such  a  manner 
as  to  leave  a  loop  several  inches  long.  This  is  then  passed  around  the  pro- 
lapsed cord  and  slipped  over  the  tip  of  the  bougie.  By  this  means  the  cord 
can  readily  be  carried  up  into  the  uterus,  after  which  it  may  be  freed  from 
the  repositor  by  bringing  the  loop  in  contact  with  a  portion  of  the  child 
and  making  traction  upon  it  so  as  to  cause  it  to  slip  off  from  the  tip  of  the 
bougie.  In  the  great  majority  of  cases  the  condition  recurs  as  soon  as  the 
repositor  is  removed;  to  insure  against  any  risk  of  such  an  accident,  the 
bougie  may  be  left  in  the  uterus. 

Occasionally  the  tendency  to  prolapse  may  be  overcome  by  placing  the 
patient  in  the  knee-chest  position  until  engagement  of  the  presenting  part 
occurs,  when  the  cord  cannot  get  past  it.  In  most  cases,  however,  these 
manoeuvres  prove  ineffectual,  and  the  death  of  the  child  becomes  almost 
inevitable  in  vertex,  and  only  somewhat  less  so  in  breech  and  transverse 
presentations. 

In  exceptional  cases,  if  the  child  is  in  good  condition,  excellent  results 
may  be  obtained  by  manual  dilatation  of  the  cervix,  followed  by  prompt 
version  and  extraction.     On  the  other  hand,  if  the  pulsations  in  the  cord 


ASPHYXIA  749 

are  weak  or  have  ceased  altogether,  such  a  procedure  should  never  be  adopt- 
ed, inasmuch  as  the  child  has  either  already  perished  or  will  die  before  de- 
livery can  be  effected.  If,  however,  the  cervix  is  fully  dilated,  such  limi- 
tations do  not  hold  good,  as  occasionally  a  child  thai  is  apparently  hopelessly 
losl  may  be  rescued. 

Asphyxia. — Normally,  the  foetus  while  it  remains  in  the  uterus  is  in  a 
condition  of  apncea,  being  satisfactorily  supplied  with  oxygen  by  means  of 
the  placental  circulation.  A-  soon  as  delivery  occurs,  owing  to  the  sepa- 
ration of  the  placenta  or  to  a  great  diminution  in  its  area  of  attachment, 
this  source  of  oxygen  is  entirely  cut  off,  or  so  greatly  reduced  that  the 
necessity  for  active  respiration  arises.  Generally  speaking,  imperfect  oxy- 
genation should  be  considered  as  the  primary  factor  in  the  establishment 
of  this  function,  although  numerous  accessory  causes  come  into  play  during 
the  act  of  delivery  and  just  after  birth. 

Exceptionally,  as  the  result  of  the  death  of  the  mother,  compression  of 
the  prolapsed  cord,  premature  separation  of  the  placenta,  or  much  less 
commonly  of  tetanic  contraction  of  the  uterus,  the  normal  supply  of  prop- 
erly  aerated  blood  through  the  umbilical  vessels  may  be  cut  off  or  interfered 
with  while  the  child  is  still  within  the  uterus.  Occasionally,  a  similar 
condition  may  be  brought  about  by  compression  against  the  symphysis  of 
a  cord  which  is  wrapped  around  the  neck  of  the  child,  while  now  and  again 
asphyxia  and  even  death  may  result  when  the  head  is  on  the  perinasum, 
owing  to  excessive  retraction  of  the  active  segment  of  the  uterus,  with  a 
consequent  diminution  in  the  area  of  placental  attachment. 

As  a  result  of  the  action  of  any  of  these  factors,  the  child  may  take  its 
first  breath  while  still  in  the  uterus  or  in  the  lower  portion  of  the  birth  canal. 
In  the  former  case  it  draws  a  certain  quantity  of  amniotic  fluid  into  its 
lungs,  unless  such  an  eventuality  is  rendered  impossible  by  the  fact  that  the 
mouth  and  nose  are  closelv  applied  to  the  uterine  wall  or  are  covered  by 
the  fcetal  membranes.  AVhen  respiration  begins  while  the  head  is  in  the 
vagina,  a  certain  amount  of  mucus  is  liable  to  be  aspirated.  In  either  event 
the  needed  oxygen  is  not  obtained,  and  the  resulting  air  hunger  leads  to 
increased  respiratory  efforts,  which  are  nevertheless  of  no  avail.  Gradually 
the  accumulation  of  carbon  dioxide  and  other  excrementitious  materials  in 
the  foetal  organism  leads  to  such  a  pronounced  decrease  in  the  irritability  of 
the  medulla,  that  eventually  the  attempts  at  respiration  cease,  the  intervals 
between  the  pulsations  of  the  heart  become  longer  and  longer,  and  the 
child  dies  from  asphyxia. 

Again,  pressure  exerted  upon  the  brain  in  difficult  labours  and  operative 
procedures  may  lead  to  vagus  irritation  and  consequent  slowing  of  the  heart. 
As  a  result  of  the  interference  with  the  fcetal  circulation,  the  blood  becomes 
poorer  in  oxygen  and  richer  in  excrementitious  material;  this  goes  on  until 
at  last  the  irritability  of  the  medulla  becomes  so  lowered  that  the  usual 
stimuli  fail  to  call  forth  the  first  respiratory  movement  and  asphyxia  results. 

The  most  frequent  causes  of  cerebral  compression  are  attempts  on  the 
part  of  the  uterus  to  force  the  head  through  a  contracted  superior  strait, 
excessive  pressure  exerted  by  the  blades  of  the  forceps,  and  intra-cranial 
haemorrhage.     "When  limited  to  the  cerebral  hemispheres,  a  very  consider- 


T50  OBSTETRICS 

able  effusion  of  blood  may  occur  without  exerting  a  deleterious  effect  upon 
the  foetus;  but  if  the  base  of  the  brain  is  implicated  a  much  smaller  amount 
may  give  rise  to  serious  disturbances. 

Diagnosis. — The  importance  of  watching  for  manifestations  pointing 
to  threatened  intra-uterine  asphyxia  cannot  be  overestimated,  inasmuch  as 
their  recognition  frequently  affords  the  indication  for  operative  delivery, 
without  which  the  life  of  the  child  is  inevitably  lost. 

The  most  characteristic  symptom  is  afforded  by  changes  in  the  foetal 
pulse-rate.  At  first,  as  a  result  of  momentary  compression  of  the  brain  or 
interference  with  the  placental  circulation,  it  becomes  slower  with  each 
uterine  contraction,  but  regains  its  normal  frequency  in  the  intervals  be- 
tween the  pains.  As  the  condition  becomes  more  serious  the  remissions 
fail  to  occur,  and  the  pulse  becomes  slower  and  slower  and  eventually  the 
heart  ceases  to  beat.  For  practical  purposes  it  is  well  to  assume  that  a 
pulse-rate  of  100  or  less  is  incompatible  with  prolonged  life  for  the  foetus, 
and  under  such  circumstances  rapid  delivery  is  indicated,  provided  it  can  be 
accomplished  without  too  great  risk  for  the  mother.  Exceptionally,  the 
first  sign  of  asphyxia  is  a  marked  increase  in  the  frequency  of  the  foetal 
pulse,  which  may  vary  from  160  to  200.  The  acceleration,  however,  is  only 
transient,  and,  as  a  rule,  soon  gives  place  to  a  marked  slowing,  which  be- 
comes still  more  perceptible  as  the  fatal  termination  is  approached. 

In  vertex  presentations  another  characteristic  sign  of  impending  as- 
phyxia is  the  escape  of  meconium.  This  is  due  to  relaxation  of  the  sphinc- 
ter ani  muscle  induced  by  faulty  aeration  of  the  blood.  In  breech  presen- 
tations, of  course,  this  symptom  is  without  significance,  and  is  to  be  regard- 
ed as  a  purely  mechanical  result  of  pressure  applied  to  the  abdomen  of  the 
foetus.  Accordingly,  whenever  the  amniotic  fluid  in  a  vertex  presentation 
presents  a  yellowish-green  appearance  and  contains  flakes  of  meconium,  we 
may  conclude  that  the  child  is  in  danger,  and  that  the  only  hope  for  its 
safety  lies  in  prompt  delivery. 

Especially  in  difficult  breech  extractions,  when  delay  is  experienced  in 
delivering  the  head,  signs  of  asphyxia  may  appear  in  a  child  which  was  ap- 
parently in  excellent  condition  before  the  operation.  Under  such  circum- 
stances the  finger  in  the  child's  mouth  can  readily  appreciate  the  fact  that 
vigorous  inspiratory  movements  are  being  made.  A  similar  phenomenon 
may  occasionally  be  observed  in  vertex  presentations,  when  the  head  is 
arrested  on  the  pelvic  floor,  the  movements  of  the  mouth  being  felt  or  seen 
through  the  thinned-out  perinseum. 

Very  exceptionally  the  child  may  not  only  make  inspiratory  efforts,  but 
actually  give  utterance  to  sounds  in  utero — vagitus  uterinus.  For  the  pro- 
duction of  this  phenomenon  it  is  essential  that  air  gain  access  to  the  foetus, 
its  entrance  into  the  uterus  sometimes  resulting  from  the  introduction  of 
the  hand  or  instruments.  A  very  characteristic  example  of  this  phenome- 
non has  been  recorded  by  Gummert,  who  has  collated  most  of  the  recent 
literature  bearing  upon  the  subject. 

After  delivery,  the  asphyxiated  child  may  present  one  of  two  appear- 
ances— asphyxia  pallida  or  asphyxia  livida.  In  both  respiration  is  in  abey- 
ance or  occurs  only  in  gasps,  while  the  heart  beats  slowly  and  feebly.     In 


asphyxia  751 

the  former  the  surface  oL'  the  body  is  pale  and  cold,  the  extremities  hang 
limp,  and  the  child  fails  to  respond  to  the  usual  external  stimuli.  In  the 
latter,  on  the  other  hand,  it  presents  a  congested  or  livid  appearance,  which 
is  usually  attributed  to  overdistention  of  the  right  heart  and  the  inferior 
vena  cava.  This  form  of  asphyxia  is  usually  more  amenable  to  treatment 
than  the  pallid  variety. 

Prognosis. — Asphyxia  neonatorum  is  always  serious.  The  prognosis  is 
relatively  favourable  when  the  condition  is  due  to  mechanical  interfer- 
ence with  the  placental  circulation,  but  is  far  less  so  when  it  results  from 
injuries  to  the  brain,  such  as  intra-cranial  haemorrhage,  fractures,  or  de- 
pressions of  the  skull. 

Treatment. — Normally,  the  child  should  make  its  first  inspiratory  move- 
ment a  few  moments  after  it  emerges  from  the  vulva.  If  this  does  not 
occur,  the  feet  being  grasped  by  the  fingers  of  one  hand  and  the  child  sus- 
pended with  its  head  downward,  its  body  should  be  slapped  vigorously  with 
the  other.  If  this  manoeuvre  does  not  prove  immediately  successful,  and 
particularly  if  attempts  at  respiration  are  associated  with  a  gurgling  sound, 
a  finger  should  be  passed  to  the  back  of  the  pharynx  for  the  purpose  of 
removing  any  foreign  material  which  may  interfere  with  the  free  access  of 
air  to  the  laryngeal  opening.  Ordinarily,  if  the  child  is  not  deeply  asphyx- 
iated, these  measures  will  bring  about  the  desired  results;  but  if  they  fail, 
artificial  respiration  should  at  once  be  instituted,  the  child's  thorax  being 
compressed  5  or  6  times  to  the  minute. 

In  some  instances,  however,  more  radical  measures  will  be  found  neces- 
sary. In  such  cases  the  cord  should  be  ligated  and  cut  through,  and  the 
child  immersed  in  hot  and  cold  water  alternately,  with  only  its  head  pro- 
truding, and  rubbed  vigorously.  If  there  is  any  reason  to  believe  that  the 
bronchial  tubes  contain  mucus  or  amniotic  fluid,  a  small,  soft-rubber  cathe- 
ter should  be  introduced  into  the  larynx  and  the  offending  material  removed 
by  suction  exerted  by  the  obstetrician,  or  by  the  employment  of  a  Eibe- 
mont-Dessaignes  insufflator. 

If  these  measures  do  not  lead  to  the  establishment  of  respiration,  the 
child  should  be  wrapped  in  a  piece  of  blanket  or  flannel,  to  prevent  too 
rapid  cooling,  and  laid  upon  a  table  or  chair,  the  head  being  allowed  to 
hang  over  the  edge.  The  tip  of  the  tongue  is  then  grasped  by  a  small 
pair  of  artery  forceps  and  drawn  forward  as  far  as  possible  and  then  allowed 
to  recede,  the  manoeuvre  being  repeated  at  regular  intervals  10  or  15  times 
to  the  minute.  After  the  first  few  tractions,  an  inspiratory  movement  usu- 
ally follows,  after  which  respiration  goes  on  regularly.  This  procedure, 
known  as  Laborde's  method  of  resuscitation ,  is  based  upon  the  principle  that 
traction  upon  the  tongue  irritates  the  fibres  of  the  superior  laryngeal,  glosso- 
pharyngeal and  lingual  nerves,  which  in  turn  give  rise  to  a  reflex  stimu- 
lation of  the  phrenic  nerves  with  consequent  contraction  of  the  diaphragm 
and  the  intercostal  muscles.  Generally  speaking,  it  is  the  most  effective 
measure  at  our  disposal,  and  the  prognosis  becomes  extremely  gloomy  if 
its  employment  is  not  attended  by  satisfactory  results  within  a  few  minutes. 
Occasionally  its  efficiency  may  be  heightened  by  practising  it  with  the  child 
immersed  in  a  hot  bath. 


752 


OBSTETRICS 


Before,  however,  despairing  of  saving  the  child's  life,  recourse  may  be 
had  to  Schultze's  method.     In  this  manoeuvre,  as  shown  in  Figs.  621  and 

622,  the  child  is  seized  by  both  hands  in  such 
a  manner  that  the  index  fingers  of  the  opera- 
tor lie  under  its  axillae,  the  thumbs  over  the 
thorax,  while  the  palmar  surfaces  of  the  re- 
maining fingers  are  applied  to  its  back,  the 
head  at  the  same  time  being  fixed  by  the  balls 
of  the  thumbs.  The  obstetrician  stands  with 
his  legs  apart  and  at  first  allows  the  foetus  to 
hang  down  between  them,  he  then  slowly  car- 
ries the  child  over  his  head  in  such  a  manner 
that  the  legs  fall  towards  its  face,  so  that  the 
body  becomes  sharply  flexed,  after  which  he 
brings  it  back  to  its  original  position.  The 
manoeuvre  is  repeated  4  or  5  times  a  minute. 
The  rationale  of  the  method  is  readily  appre- 
ciated: the  thorax  is  markedly  compressed 
when  the  child  is  elevated  and  expanded  when 
it  is  lowered,  the  two  positions  favouring  ex- 
piration and  inspiration  respectively. 

Some  idea  of  its  efficiency  may  be  gained 
by  the  fact  that,  when  it  is  practised  upon  a 
dead  child,  air  can  be  distinctly  heard  to  enter 
and  leave  the  lungs  with  each  movement.  The 
procedure,  however,  is  not  without  peculiar 
disadvantages.  In  the  first  place,  its  employ- 
ment sometimes  gives  rise  to  fracture  of  the 
clavicles  or  ribs,  and  occasionally  to  rupture 
of  the  liver  or  other  serious  lesions  of  the  in- 
ternal organs.  Moreover,  in  view  of  the  no 
small  degree  of  violence  associated  with  its 
use,  the  manoeuvre  is  contra-indicated  in  those 
cases  in  which  the  clavicle  or  humerus  have 
been  fractured  during  a  difficult  extraction, 
inasmuch  as  the  free  ends  of  the  bones  are 
liable  to  cause  serious  injury  to  the  soft  parts. 
Byrd,  in  1874,  suggested  a  convenient  sub- 
stitute for  Schultze's  method.  He  recom- 
mended that  the  back  of  the  child  be  allowed 
to  rest  upon  the  palmar  surface  of  both  hands, 
the  ulnar  margins  being  almost  in  apposition, 
while  the  thumb  of  one  hand  is  applied  over 
the  sternum  and  the  other  over  the  thighs. 
By  approximating  the  radial  margins  of  the 
hands,  the  operator  can  then  bring  the  child's 
head  and  feet  closely  together,  thereby  com- 
pressing the  thorax  and  causing  expiration, 


622. 


Tigs.  821,  622. — Schultze's  Method 
oe  Eesuscitation. 


SUDDEN    DKATII    DURIXd    OK    SHORTLY    AI-TKK    LAHOUB  ,■•■'. 

while  a  movemenl  in  the  opposite  direction  brings  about  extreme  expas 
and  favours  inspiration. 

In  obstinatr  cases,  beneficial  results  sometimes  follow  the  hypodermic 
injection  of  a  few  drops  of  whisky  or  ether. 

When  the  asphyxia  is  the  result  of  a  depressed  fracture  of  the  skull  it 
may  be  permissible  to  make  a  small  perforation  through  which  the  blade 
of  a  pair  of  scissors  or  some  other  suitable  instrument  is  introduced;  and 
an  effort  made  to  replace  the  depressed  portion  and  thus  remove  the 
source  of  compression.  Such  an  operation,  however,  should  be  attempted 
only  when  other  procedures  have  failed,  and  provided  that  the  heart  still 
continues  to  brat  strongly,  though  slowly. 

Efforts  at  resuscitation  should  be  persevered  in  as  long  as  the  heart 
continues  to  heat,  one  method  after  another  being  given  a  trial.  The  neces- 
sity for  persistence  is  shown  by  the  fact  that  successful  results  are  not 
unusual  after  trials  lasting  for  thirty  to  sixty  minutes,  or  even  longer. 

Sudden  Death  during  or  shortly  after  Labour. — Ordinarily,  death  occur- 
ring during  labour,  or  in  the  first  few  hours  immediately  following  it,  is 
the  result  of  some  one  of  the  abnormalities  to  which  allusion  has  already 
been  made,  particularly  acute  oedema  of  the  lungs  or  apoplexy  complicating 
eclampsia,  or  acute  ana?mia  the  result  of  post-partum  haemorrhage,  placenta 
praevia,  premature  separation  of  the  normally  implanted  placenta,  or  rup- 
ture of  the  genital  canal. 

In  rare  instances,  incomplete  rupture  of  the  uterus  is  unattended  by 
symptoms  at  the  time  of  its  occurrence,  the  blood  slowly  accumulating  be- 
tween the  folds  of  the  broad  ligament  with  a  gradual  development  of  symp- 
toms of  shock.  A  subperitoneal  haeniatoma  formed  in  this  way  is  liable  to 
rupture  into  the  peritoneal  cavity  at  any  time  within  the  first  forty-eight 
hours  after  delivery  and  lead  to  sudden  death. 

Moreover,  a  woman  in  labour,  or  during  the  puerperium.  may  die  sud- 
denly from  the  effects  of  any  condition  which  would  give  rise  to  a  similar 
outcome  under  other  circumstances.  Thus,  cases  have  been  reported  in 
which  the  fatal  termination  was  due  to  rupture  of  an  aortic  or  cardiac 
aneurysm,  haemorrhage  from  a  gastric  ulcer,  or  other  accidents.  Van  der 
Yelde  has  reported  a  case  of  a  fatal  retro-peritoneal  haemorrhage  compli- 
cating an  acute  pancreatitis,  while  Xode  and  Hines  observed  sudden  death 
during  labour  following  the  rupture  of  an  aneurysm  of  the  splenic  artery. 

In  the  chapter  dealing  with  the  Pathology  of  Pregnancy  reference  was 
made  to  the  consequences  of  labour  in  women  suffering  from  valvular  lesions 
of  the  heart,  particularly  stenosis  of  the  mitral  orifice.  Less  frequently, 
sudden  death  may  be  due  to  fatty  degeneration  or  to  changes  in  the  myo- 
cardium. Such  accidents  are  to  be  particularly  dreaded  in  elderly  and 
corpulent  women. 

Shod-. — Formerly  it  was  customary  to  attribute  a  certain  number  of 
deaths  following  labour  to  shock,  which  was  supposed  to  occur  in  certain 
individuals  after  prolonged  and  very  painful  labours,  the  incidental  loss 
of  rest,  imperfect  nutrition,  and  mental  excitement  being  looked  upon  as 
predisposing  causes.  In  the  present  state  of  our  knowledge,  however,  this 
explanation  is  hardly  permissible,  since  in  the  majority  of  such  cases  a 
49 


754  OBSTETRICS 

carefully  performed  autopsy  will  reveal  the  existence  of  some  condition 
sufficiently  serious  to  account  for  the  unfavourable  outcome,  the  most  com- 
mon being  haemorrhage  following  some  severe  injury  to  the  genital  tract. 

Syncope. — Faintness  is  not  an  uncommon  result  of  exhaustion  following 
prolonged  labour,  and  in  neuropathic  individuals  may  occur  even  after  an 
easy  and  rapid  delivery.  In  rare  instances  it  may  be  due  to  cerebral  ansemia 
resulting  from  lack  of  blood  in  the  nervous  centres  following  the  sudden 
diminution  in  the  intra-abdominal  pressure  incident  to  the  rapid  decrease 
in  the  size  of  the  uterus. 

The  faintness  usually  passes  off  rapidly  and  does  not  lead  to  untoward 
results.  On  the  other  hand,  it  occasionally  gives  cause  for  serious  alarm, 
the  pulse  becoming  weaker  and  more  rapid  and  the  patient  remaining  in  a 
condition  of  profound  prostration.  I  have  never  seen  a  death  from  this 
cause,  but  can  recall  one  patient  who  caused  me  the  greatest  possible 
anxiety,  and  who  was  in  imminent  danger  for  more  than  twelve  hours. 

Haig  Ferguson  reports' 3  cases  of  serious  exhaustion  following  labour 
in  which  he  was  inclined  to  attribute  the  condition  to  reflex  irritation  re- 
sulting from  pressure  upon  the  ovaries  incident  to  the  improper  employ- 
ment of  Creole's  method  of  expressing  the  placenta,  the  organ  being  grasped 
laterally  instead  of  antero-posteriorly. 

Profound  Mental  Depression. — In  rare  instances  the  only  apparent  ex- 
planation for  death,  or  for  a  profound  collapse  which  eventuates  in  recov- 
ery, is  to  be  found  in  the  mental  condition  of  the  patient,  since  the  most 
careful  examination,  both  at  the  bedside  and  at  autopsy,  may  fail  to  reveal 
the  slightest  abnormality. 

I  recall  a  case  in  my  own  practice  which  apparently  belongs  in  this 
category.  The  patient,  who  was  unhappily  married,  had  already  passed 
through  two  very  difficult  labours.  When  I  saw  her,  in  the  latter  part 
of  the  first  stage  of  her  third  labour,  she  was  abo^^t  the  room.  Just  be- 
fore going  to  bed  at  the  beginning  of  the  second  stage  she  asked  the 
nurse  and  myself  to  witness  her  will,  as  she  said  she  felt  sure  she  would 
not  recover.  The  labour  was  rapid  and  uneventful,  the  placenta  coming 
away  spontaneously,  and  everything  appearing  to  be  most  satisfactory.  On 
approaching  the  bed  to  take  leave  of  the  patient  half  an  hour  later,  I  was 
struck  with  her  haggard  appearance.  Fearing  the  possibility  of  hgemor- 
rhage, I  at  once  applied  my  hand  over  the  uterus  and  found  it  tightly  con- 
tracted, while  the  pulse  was  of  excellent  quality.  Without  any  apparent 
reason,  and  in  spite  of  energetic  stimulation  and  the  subcutaneous  adminis- 
tration of  salt  solution,  the  patient  grew  slowly  worse,  the  pulse  becoming 
rapid  and  weak,  the  eyes  sinking  back  in  their  sockets,  and  the  face  assuming 
a  drawn  and  Hippocratic  expression. 

The  most  careful  examination  failed  to  reveal  the  slightest  cause  for 
the  condition.  The  hand  introduced  into  the  uterus  could  find  no  trace 
of  rupture.  Eight  hours  after  delivery  I  requested  a  colleague  to  see  her 
in  consultation,  but  he  also  was  unable  to  offer  any  explanation.  It  then 
occurred  to  me  that  the  condition  might  possibly  be  the  result  of  her  mor- 
bid forebodings,  and  acting  upon  this  supposition  I  administered  a  large 
dose  of  morphine  hypodermically,  which  was  promptly  followed  by  sound 


SUDDEN  DEATB  DURING  OB  SHORTLY  AFTEB  LABOUR    7:>."> 

sleep,  a  marked  Lmprovemenl  in  the  character  of  the  pulse,  and  a  rapid 
change  for  the  better  in  the  general  appearance.  Upon  awaking  a  few 
hours  Later,  the  patienl  felt  very  comfortable  and  made  an  uninterrupted 
recovery. 

Pulmonary  Embolism. — This  accident,  usually  noted  only  Later  in  the 
puerperium,  bui  occasionally  occurring  shortly  after  Labour,  is  duo  to  the 
detachment  of  a  small  particle  of  thrombus  situated  in  a  uterine  or  pelvic 
vein  or  elsewhere,  which  is  carried  to  the  right  side  of  the  heart  and  loads 
to  more  or  less  complete  occlusion  of  the  pulmonary  artery.  Under  such 
circumstances  the  patient  complains  of  intense  and  sudden  precordial  pain, 
becomes  Livid  in  appearance,  and  presents  symptoms  of  profound  dyspnoea 
and  eventually  of  air  hunger.  These  embolisms,  however,  are  not  always 
fatal,  a  small  proportion  of  the  patients  recovering. 

The  treatment  is  purely  palliative.  The  woman  should  be  placed  in  the 
recumbent  position,  stimulants  by  the  mouth  and  salt  solution  subcutane- 
ously  should  be  administered.  Inhalations  of  oxygen,  if  obtainable,  are 
also  indicated. 

Entrance  of  Air  into  the  Uterine  Sinuses. — Certain  cases  of  death  follow- 
ing mtra-uterine  manipulations  in  women  suffering  from  placenta  prsevia 
or  rupture  of  the  uterus,  are  attributed  by  many  authorities  to  the  entrance 
of  air  into  the  uterine  sinuses,  whence  it  is  carried  to  the  heart.  The 
exact  cause  of  death  is  not  understood,  some  holding  that  the  air  bubbles 
enter  the  coronary  arteries,  and  others  that  the  right  heart,  being  unable 
to  rid  itself  of  them,  becomes  paralyzed  as  a  result  of  its  fruitless  efforts. 

The  symptoms  are  analogous  to  those  following  pulmonary  embolism. 
Cases  of  this  character  have  been  reported  by  Olshausen,  Lesse,  Perkins, 
Roger,  and  others. 

That  such  a  condition  occasionally  occurs  is  clear  from  the  fact  that 
several  cases  have  been  reported  in  which  sudden  death  followed  the  injec- 
tion of  air  into  the  pregnant  uterus  for  the  purpose  of  producing  abortion. 
On  the  other  hand,  it  is  probable  that  its  frequency  has  been  much  over- 
estimated, and  that  not  a  few  of  the  cases  which  have  come  to  autopsy,  and 
which  were  supposed  to  demonstrate  such  a  possibility,  are  open  to  another 
and  far  more  reasonable  explanation.  Thus,  G.  W.  Dobbin,  in  my  clinic, 
was  able  to  demonstrate  the  presence  of  Bacillus  aerogenes  capsulatus  in  the 
tissues  from  one  of  Perkins's  cases,  in  which  the  presence  of  air  bubbles 
in  the  blood-vessels  had  been  regarded  as  satisfactory  evidence  as  to  the 
cause  of  death.  Wendeler  had  a  similar  experience,  and  it  would  there- 
fore seem  permissible  to  regard  with  scepticism  all  cases  of  supposed  air 
embolism  in  which  death  did  not  occur  almost  instantaneously,  or  in  which 
careful  bacteriological  investigation  demonstrated  the  presence  of  gas 
bacilli. 

Post-mortem  Delivery. — In  the  literature,  which  has  been  carefully 
searched  by  Aveling  and  Reimann,  a  number  of  cases  are  recorded  in 
which  spontaneous  birth  of  the  child  took  place  some  hours  or  days  after 
the  death  of  the  mother.  ^Moreover,  delivery  sometimes  occurs  after  burial. 
and  when  the  body  has  been  exhumed  for  some  reason  two  individuals 
instead  of  one  have  been  found  in  the  coffin.     These  are  instances  of  the 


756  OBSTETRICS 

so-called  "  coffin  birth."  The  phenomenon  is  usually  observed  in  multip- 
arous  women  in  whom  the  vaginal  outlet  is  markedly  relaxed,  and  is  sup- 
posed to  be  due  to  a  marked  increase  in  the  intra-abdominal  pressure  pro- 
duced by  putrefactive  changes,  though  certain  authorities  are  inclined  to 
attribute  isolated  cases  to  rigor  mortis  of  the  uterine  musculature. 


LITERATURE 

Aveling.     On  Post-mortem  Parturition,  with  References  to  Forty-four  Cases.     Trans. 

London  Obst.  Soc,  1873,  xiv,  240-258. 
Byrd.     A  Speedy  Method  in  Asphyxia.     The  Obst.  Jour,  of  Great  Britain  and  Ireland, 

1874,  i,  65-69,  Amer.  Supplement. 
Dobbin.     Bemerkungen  zu  den  Arbeiten  von  Schnell,  Wendeler  und  Goebel :    Ueber 

einen  Fall  von  Gasblasen  im  Blute  einer  nach  Tympania  uteri  gestorbenen  Puerpera. 

Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  vir  375-379. 
Ferguson.     On  a  Variety  of  Post-partum  Shock,  its  Nature,  Cause,  and  Prevention. 

Edinburgh  Med.  Jour.,  1899,  xxxv,  32-41. 
Gummert.     Ueber  vagitus  uterinus.     Monatsschr.  f.  Geb.  u.  Gyn.,  1899,  ix,  492-496. 
Laborde.     Les  tractions  rhythmees  de  la  langue,  moyen  rationnel  et  puissant  de  ranimer 

la  fonction  respiratoire  et  la  vie.     Paris,  1894. 
Lesse.     Ein  weiterer  Fall  von  Luf tembolie  bei  Placenta  prsevia.     Zeitschr.  f .  Geb.  u.  Gyn., 

1896,  xxxv,  184-191. 
Nodes  and  Hines.     Fatal  Rupture  of  an  Aneurysm  of  the  Splenic  Artery  immediately 

after  Labour.     Trans.  London  Obst.  Soc,  1900,  xlii,  305-310. 
Olshausen.     Ueber  Lufteintritt  in  die  Uterusvenen.     Monatsschr.  f.   Geburtsk.,  1864, 

xxiv,  350-374. 
Perkins.     Air  Embolism,  etc.     Boston  Med.  and  Surg.  Jour.,  1897,  February  18  and  29. 
Reimann.     Ueber  Geburten  nach  dem  Tode  der  Mutter.     Archiv  f.  Gyn.,  1877,  xi,  215- 

255. 
Roger.     Etude  clinique  sur  la  phenomene  de  l'entree  de  l'air  par  les  sinus  uterins  dans 

l'etal  puerperal.     These  de  Paris,  1899. 
Schultze.     Ueber  die  beste  Methode  der  Wiederbelebung  scheintodt  geborener  Kinder. 

Jenaische  Zeitschr.  f.  Med.  u.  Naturwissensch.,  1866,  iii,  Heft  4. 
Der  Seheintod  Neugeborener.     Jena,  1871. 
Van  der  Velde.     Ein  Fall  von  todtlicher  Pancreasblutung,  etc.     Ref.  Frommel's  Jahres- 

bericht,  1898,  764. 
Wendeler.     Ueber  einen  Fall  von  Gasblasen  im  Blute  einer  nach  Tympania  uteri  gestor- 
benen Puerpera.     Monatsschr.  f.  Geb.  u.  Gyn.,  1896,  iv,  581-583. 


PATHOLOGY  OF  THE  PUERPERIUM 

CHAPTEK    XLIV 
P UERPERA  L   IXFECTION 

Under  the  general  heading  of  "  puerperal  infection  "  are  now  included 
all  the  various  morbid  conditions  which  result  from  the  entrance,  during 
labour  or  the  puerperium,  of  infective  micro-organisms  into  the  female 
generative  tract.  The  older  term,  "  puerperal  fever,"  is  at  once  too  vague 
and  misleading,  and  for  many  reasons  should  be  discarded.  In  the  first 
place,  it  suggests  the  old  idea  of  the  essentiality  of  the  affection  so  strongly 
urged  in  this  country  by  the  late  Fordyce  Barker,  and  takes  no  account  of 
the  various  ^etiological  factors  which  may  be  concerned.  Moreover,  it 
emphasizes  the  febrile  phenomena  of  the  affection,  instead  of  laying  stress 
upon  its  infectious  nature  and  the  consequent  responsibility  of  the  obstetri- 
cian and  his  assistants.  Again,  "  puerperal  septicaemia  "  and  "  puerperal 
sepsis,"  which  are  often  used  as  synonymous  terms,  are  hardly  less  satis- 
factory, inasmuch  as  in  many  instances  the  infection  results  in  perfectly 
localized  inflammatory  processes,  to  which  such  terms  cannot  be  applied 
without  violating  the  established  rules  of  diction. 

It  is  probable  that  puerperal  infection  has  occurred  almost  as  long  as 
children  have  been  born,  and  passages  in  the  works  of  Hippocrates,  Galen, 
Avicenna,  and  many  of  the  old  writers,  clearly  have  reference  to  it.  As 
early  as  1676,  "Willis  wrote  on  the  subject  of  febris  puerperarum,  but  the 
English  term  "  puerperal  fever  "  probably  was  first  employed  by  Strother 
in  1718. 

The  ancients  regarded  the  affection  as  the  result  of  retention  of  the 
lochia,  and  for  centuries  this  explanation  was  universally  accepted.  In 
the  early  part  of  the  seventeenth  century  Plater  showed  that  it  was  essen- 
tially a  metritis,  and  was  followed  in  the  next  century  hj  Puzos  with  his 
milk  metastasis  theory.  From  the  time  of  Plater,  until  Semmelweiss  proved 
its  identity  with  wound  infection,  and  Lister  demonstrated  the  value  of 
antiseptic  methods,  all  sorts  of  theories  were  suggested  concerning  its  origin 
and  nature,  which  are  comprehensively  dealt  with  in  the  monographs  of 
Eisenmann  and  Silberschmidt. 

Organisms  Causing  Puerperal  Infection. — In  1 847_  Semmelweiss.  then 
an  assistant  in  the  Vienna  Lying-in  Hospital,  began  a  careful  inquiry  into 
the  causes  of  the  frightful  mortality  attending  labour  in  that  institution, 
as  compared  with  the  small  number  of  women  succumbing  to  puerperal 
infection  when  delivered  in  their  own  homes.     As  a  result  of  his  observa- 


758  OBSTETRICS 

tions,  lie  concluded  that  the  morbid  process  was  essentially  a  wound  infec- 
tion, and  was  due  to  the  introduction  of  septic  material  by  the  examining 
finger.  Acting  upon  this  idea  he  issued  stringent  orders  that  the  physicians, 
students,  and  midwives  should  disinfect  their  hands  with  chlorine  water  be- 
fore examining  parturient  women.  In  spite  of  almost  immediate  surpris- 
ing results — the  mortality  falling  from  over  10  to  about  1  per  cent — his 
work  was  scoffed  at  by  many  of  the  most  prominent  men  of  his  time,  and 
his  discovery  remained  unappreciated  until  the  influence  of  Lister's  teach- 
ings and  the  development  of  bacteriology  had  brought  about  a  revolution 
in  the  treatment  of  wounds. 

Among  the  principal  organisms  which  have  been  proved  to  be  causes  of 
puerperal  infection  are  the  following: 

(a)  Streptococcus. — The  Streptococcus  pyogenes  is  the  most  frequent 
cause  of  the  epidemic  and  fatal  forms  of  puerperal  infection.  As  early 
as  1865  this  organism  was  observed  in  the  tissues  of  women  who  had  died 
during  the  puerperium,  by  Mayrhofer,  whose  findings  were  confirmed  by 
Coze  and  Feltz,  Recklinghausen,  Waldeyer,  KLebs,  Orth,  Heiberg,  and  Lan- 
dau. Pasteur,  in  1880,  however,  was  the  first  to  cultivate  streptococci  from 
cases  of  puerperal  infection,  and  he  called  them  "  chapelets  en  grains."  He 
was  assisted  in  this  work  by  Doleris,  who  carried  it  still  further,  and  showed 
that  the  streptococcus  was  generally  the  infectious  agent,  but  that  staphy- 
lococci, and  occasionally  bacilli,  were  sometimes  responsible  for  the  infec- 
tion. These  researches  were  soon  confirmed  by  Lomer,  Bumm,  Doderlein, 
Winter,  Widal,  and  by  all  subsequent  observers. 

(b)  Staphylococcus. — Further  investigation  gradually  demonstrated  the 
fact  that  the  streptococcus  is  not  necessarily  the  only  organism  which  may 
be  concerned,  but  that  most  of  the  pus  producers,  which  give  rise  to 
wound  infection  in  other  parts  of  the  body,  may  likewise  at  times  be  the 
exciting  factors. 

Brieger,  in  1888,  reported  autopsies  upon  7  women  who  had  died  after 
a  febrile  puerperium,  in  5  of  which  he  demonstrated  Staplrylococcus  aureus. 
Doleris,  in  his  thesis  of  1880,  stated  that  he  had  been  able  in  similar 
cases  to  cultivate  in  pure  culture  cocci  arranged  in  groups  or  bunches, 
but  it  was  not  until  1891  that  he  stated  definitely  that  they  were  staphy- 
lococci. 

The  statement  made  hy  Fehling  and  Haegler  that  staphylococci  usually 
give  rise  to  mild  forms  of  infection,  has  not  been  borne  out  by  the  observa- 
tions of  other  investigators.  Occasionally  mixed  infections  with  staphy- 
lococcus and  streptococcus  are  observed,  as  reported  by  Doderlein  and  Bar 
and  Tissier.  It  appears  that  Staphylococcus  aureus  is  the  variety  observed 
in  puerjDeral  infection,  the  albus  and  citreus  playing  little  or  no  part  in  its 
production. 

(c)  Gonococcus. — Although  clinicians  had  long  suspected  that  gonor- 
rhoea not  infrequently  plays  a  part  in  the  production  of  puerperal  infec- 
tion, Kronig  was  the  first  to  adduce  bacteriological  proof  of  its  action.  In 
1893  he  reported  9  cases  of  mild  infection,  in  all  of  which  he  was  able  to 
obtain  pure  cultures  of  gonococci  from  the  uterine  lochia.  In  a  more  recent 
communication  he  states  that  he  was  able  to  cultivate  the  same  organism 


IM   I.KI'KKAI.    INFECTION  759 

from  the  discharges  of  50  oul  of  L79  patients  presenting  febrile  puerperia, 
thus  showing  thai  ii  plays  an  importanl  pari  in  the  production  of  puerperal 
disease.  None  of  these  cases  ended  fatally,  mosl  of  the  patients  recovering 
spontaneously. 

Leopold  has  reported  similar  cases,  and  Maslowsky  and  Neumann  state 
thai  they  were  able  to  demonstrate  the  gonococcus  in  the  tissues  of  cases 
of  endometritis  decidiuc.  As  a  rule,  gonorrheal  infection  in  the  puer- 
perium  pursues  a  favourable  course,  but  occasionally  fatal  septicaemia  may 
result,  as  in  one  of  my  cases  reported  by  Harris  and  Dabney. 

(>/)  Bacillus  Coli  Communis. — In  the  writer's  article  (1893)  upon  puer- 
peral infection  from  a  bacteriological  point  of  view,  it  was  stated  that  von 
Franque  had  cultivated  the  colon  bacillus  from  a  case  of  puerperal  infec- 
tion, and  the  belief  was  expressed  that  it  would  be  demonstrated  more 
frequently  in  the  future.  Time  has  amply  verified  this  prediction,  and 
there  are  now  on  record  a  long  series  of  cases  due  to  this  organism.  .1 
priori,  this  is  what  would  be  expected  when  one  takes  into  consideration 
the  proximity  of  the  genital  tract  to  the  rectum,  and  the  ease  with  which 
contamination  can  occur  when  the  obstetrician  fails  to  observe  the  strictest 
asepsis. 

Some  idea  of  the  enormous  numbers  of  colon  bacilli  present  in  the 
human  body  may  be  gained  from  the  consideration  of  the  figures  of  several 
French  observers.  Thus,  Tignal  states  that  1  decigramme  of  faeces  contains 
about  20,000,000,  and  Gilbert  and  Dominici  estimate  that  from  12,000,000,- 
000  to  15,000,000,000  are  daily  excreted.  It  is  therefore  evident  that  the 
examining  finger  can  hardly  avoid  contamination  with  these  organisms  if 
it  comes  in  contact  with  a  non-disinfected  perina?um. 

Gebhard  demonstrated  their  presence  in  ?  cases  of  tympania  uteri, 
either  alone  or  in  combination  with  other  organisms,  and  Galtier  states 
that  it  is  the  organism  most  frequently  concerned  in  the  production  of  this 
condition. 

Xot  uncommonly  it  is  associated  with  the  streptococcus,  as  in  cases 
reported  by  Marmorek,  Charpentier,  Bar  and  Tissier,  and  the  writer.  Some 
observers  have  thought  that  this  combination  augments  the  virulence  of 
the  streptococcus  and  gives  rise  to  very  intense  infections. 

(e)  Bacillus  Diphtheria?. — Until  very  recently  it  was  believed  that  the 
diphtheritic  deposits  upon  the  vagina  and  the  interior  of  the  puerperal 
uterus  were  due  to  the  streptococcus  alone,  and  were  in  no  way  connected 
with  true  diphtheria.  That  this  is  not  always  the  case,  however,  has  been 
shown  by  the  recent  observations  of  Xisot,  Bumm,  the  writer,  and  others, 
who  reported  instances  in  which  the  Klebs-Loefner  bacillus  was  cultivated 
from  the  diphtheritic  membrane  in  the  vagina,  the  affection  yiel ding- 
promptly  to  the  use  of  the  anti-diphtheritic  serum. 

(f)  Bacillus  Aerogenes  Capsulatus  (Gas  Bacillus). — The  gas  bacillus  of 
TTelch  is  occasionally  concerned  in  puerperal  infection.  In  1896  the  writer 
observed  an  instance  of  this  kind,  which  was  reported  by  Dobbin.  Briefly 
stated,  the  case  was  as  follows:  An  outdoor  patient,  a  Bohemian  woman, 
with  a  generally  contracted  pelvis,  had  been  in  labour  for  some  three  to 
four  davs  under  the  care  of  a  midwife.     "When  she  came  into  our  hands 


^60  OBSTETRICS 

the  head  of  a  macerated  child  was  found  firmly  engaged  in  the  superior 
strait,  the  uterus  being  in  a  state  of  tetanic  contraction.  A  foetid,  dark- 
coloured  discharge,  which  contained  many  gas  bubbles,  was  escaping  from 
the  vagina  with  a  crackling  sound.  Owing  to  the  softened  condition  of 
the  child's  head  delivery  with  forceps  was  out  of  the  question,  and  was 
effected  by  means  of  Tarnier's  basiotribe.  The  mother  was  profoundly 
infected  at  the  time  and  died  the  next  day.  Within  a  few  hours  after 
death  her  body  had  nearly  doubled  its  original  size,  as  the  result  of  the 
development  of  gas  in  the  subcutaneous  tissues.  Similar  changes  were 
observed  in  the  foetus  and  in  the  placenta,  and  we  were  able  to  demon- 
strate the  presence  of  the  gas  bacillus  in  the  tissues  of  both,  as  well  as 
in  the  uterine  lochia.  Unfortunately  no  autopsy  was  allowed  upon  the 
mother,  and  we  were  therefore  unable  to  say  to  what  extent  the  organisms 
had  penetrated  into  her  tissues. 

Well-authenticated  instances  of  infection  with  this  organism  have  been 
reported  by  Stewart,  Ernst,  Xorris,  Wood,  Halban,  and  othersj  and  the 
entire  literature  upon  the  subject  was  exhaustively  reviewed  by  Welch 
in  1900. 

It  is  important  to  remember  that  the  gas  bubbles  which  are  found  in 
the  blood-vessels  of  women  supposed  to  have  perished  from  the  entrance  of 
air  into  the  uterine  sinuses,  are  frequently  the  product  of  the  bacillus  in 
question.  Attention  was  first  directed  to  this  point  by  Dobbin,  and  was 
still  further  insisted  upon  by  Welch,  so  that  at  present  the  diagnosis 
of  air  embolism  is  not  justifiable  unless  careful  bacteriological  examination 
has  demonstrated  the  absence  of  the  gas  bacillus. 

(g)  Bacillus  Typhosus. — In  1898,  Dobbin  and  the  writer  isolated  Bacillus 
typhosus,  streptococcus,  staphylococcus  aureus,  and  an  unidentified  anae- 
robic gas-producing  bacillus  from  the  uterine  lochia  of  a  Bohemian  woman 
who  was  admitted  to  the  Johns  Hopkins  Hospital  on  the  fifth  day  of  the 
puerperium  with  high  fever.  Her  blood  gave  the  characteristic  Widal  re- 
action, but  all  the  usual  symptoms  of  typhoid  fever  were  absent.  The 
temperature  fell  to  normal  on  the  thirteenth  day,  and  did  not  rise  again. 
We  were  inclined  to  believe  that  the  typhoid  bacilli  were  introduced  into 
her  uterus  by  the  midwife,  along  with  other  organisms,  since  she  was  deliv- 
ered upon  the  same  bed  upon  which  her  husband  had  died  of  typhoid 
fever  a  few  days  previously.  A  somewhat  similar  case  has  been  reported 
by  Blumer,  in  which  the  autopsy  revealed  an  unsuspected  typhoid  fever. 

(h)  Bacillarij  Infection. — Isolated  eases  reported  by  Fraenkel,  Doleris, 
Widal,  Mixius,  Goldscheider,  and  others,  tend  to  show  that  certain  cases 
of  fatal  infection  may  be  due  to  bacilli  with  whose  properties  we  are  as  yet 
unacquainted.  But  the  bacteriological  work  upon  which  these  statements 
are  based  is  not  of  a  character  to  enable  us  to  identify  the  organisms  in 
question,  much  less  to  classify  them.  At  the  same  time,  bacteriological  ex- 
amination of  the  uterine  lochia  in  all  cases  of  fever  in  the  puerperium,  as 
carried  out  by  Kronig  and  the  writer,  clearly  show  that  many  bacteria  with 
which  we  are  as  yet  unfamiliar  may  take  part  in  the  process.  I  have  re- 
cently seen  a  case  of  phlegmasia  alba  dolens  in  which  the  infectious  agent 
was  apparently  a  short,  thick,  anaerobic  bacillus. 


PUERPERAL   INFECTION  .«'>1 

(i)  SaprcBmia. — Besides  the  cases  in  which  the  infection  is  due  to  the 
growth  and  extension  of  micro-organisms  within  the  body,  there  is  a  large 
group  in  which  the  sj^iix>tonis  are  due  to  the  absorption  of  toxines  produced 
within  the  uterus  or  elsewhere  in  the  generative  tract  by  organisms  which 
do  not  invade  the  tissues  deeply  nor  make  their  way  into  the  blood  current. 
To  this  form  of  infection  Matthews  Duncan  some-  years  ago  applied  the 
term  "  sa pra mia."  It  is  usually  thought  to  be  due  to  the  invasion  of  the 
uterus  by  putrefactive  organisms  with  whose  properties  we  are  as  yet  almost 
totally  unfamiliar. 

No  doubt  the  term  has  heen  greatly  abused,  and  many  cases  have  been 
included  under  it  which  were  really  due  to  infection  with  the  ordinary 
pyogenic  organisms.  Xor  are  we  justified  in  considering  a  case  as  sapraemic 
unless  the  lochia  have  been  examined  bacteriologically  and  found  to  be 
free  from  pyogenic  organisms. 

This  statement  is  borne  out  by  the  observations  of  Bumm,  who  found 
streptococci  in  8  out  of  11  cases  which  were  thought  to  present  the 
clinical  picture  of  sapraemia.  A'on  Tranche  also  obtained  somewhat  simi- 
lar results,  and  concluded  that  sapramxic  fever  in  the  puerperium  is  ex- 
tremely rare,  and  should  be  diagnosed  only  after  an  accurate  bacteriological 
examination  of  the  uterine  lochia  has  demonstrated  the  absence  of  patho- 
genic and  the  presence  of  saprophytic  organisms. 

The  causative  organisms  in  saprgemia  are  mostly  of  an  anaerobic  nature, 
and  consequently  do  not  grow  on  the  usual  culture  media,  Many  of  them 
are  gas  producers,  and  cause  the  frothy,  ill-smelling  secretion  which  is  so 
characteristic  of  these  cases.  Many  different  varieties  are  undoubtedly 
concerned  in  its  production,  though  only  a  few  have  as  yet  been  isolated. 
Thus,  Bumm  cultivated  from  one  case  an  anaerobic  bacillus,  which  decom- 
posed albumin  and  produced  poisonous  substances,  while  Doderlein  isolated 
an  anaerobic  gas-producing  coccus  from  a  woman  who  presented  a  frothy, 
purulent  vaginal  discharge.  Kronig,  in  43  abnormal  puerperia,  found  or- 
ganisms which  did  not  grow  on  the  usual  media,  and  in  32  of  them  obtained 
varieties  which  were  pure  anaerobes. 

Besides  the  organisms  already  mentioned,  it  is  not  unlikely  that  further 
research  will  show  still  others  which  may  play  a  part  in  the  production  of 
isolated  cases  of  puerperal  infection;  but  to  summarize,  it  may  be  said  that 
those  most  commonly  concerned  are  the  well-known  pyogenic  organisms 
(streptococcus,  staphylococcus,  bacillus  coli,  and  gonococcus)  and  the  vari- 
ous putrefactive  varieties. 

Some  idea  of  the  relative  frequency  with  which  the  several  organisms 
occur  in  puerperal  infections  may  be  gathered  from  the  work  of  Kronig, 
who  examined  179  cases  of  puerperal  endometritis  bacteriologically,  and  as 
a  result  of  his  observations  divided  them  into  3  groups — pyogenic,  gonor- 
rhceal,  and  saprsemic.  The  pyogenic  group  comprised  79  cases,  in  75  of 
which  the  infective  agent  was  the  streptococcus,  and  in  4  the  staphylococcus. 
In  50  cases  the  gonococcus  was  isolated,  while  in  43  of  the  50  sapra?mic 
cases  the  organisms  did  not  grow  on  the  usual  culture  media,  32  of  them 
being  pure  anaerobes. 

Bacteriological  examination  of  the  uterine  lochia  in  a  series  of  150 


762 


OBSTETRICS 


cases  of  my  own,  in  which  the  temperature  rose  to  101°  F.,  or  higher,  during 
the  first  ten  days  of  the  puerperium,  gave  the  following  results: 


Streptococcus 

Streptococcus  and  bacillus  coli 

Streptococcus,  staphylococcus,  and  bacilli 

Streptococcus,  bacillus  coli,  and  gas  bacillus 

Streptococcus,  staphylococcus,  gas  and  typhoid  bacillus 

Streptococcus,  staphylococcus,  bacillus  coli,  and  gas  bacilli.. 

Streptococcus  and  unidentified  bacillus 

Staphylococcus 

Bacillus  coli 

Gonococcus 

Gonococcus  and  bacillus  coli 

Unidentified  aerobic  bacteria 

Unidentified  anaerobic  bacteria 

Bacillus  diphtherias 

Bacillus  typhosus 

Bacteria  seen  in  cover-slips,  but  which  failed  to  grow   on 

any  of  the  more  usual  media 

Absolutely  sterile 


31  cases 


2 
1 
1 

2 

4 
11 
7 
1 
4 
8 
1 
1 

45 
25 


Pathological  Anatomy. — The  lesions  may  vary  widely  even  in  cases  clin- 
ically similar,  and  these  variations  afford  a  probable  explanation  for  they 
failure  of  the  older  authors  to  appreciate  the  true  nature  of  the  affectioi 
Thus,  there  may  be  an  almost  infinite  series  of  gradations  from  a  slight 
membrane  covering  a  small  perineal  tear  to  an  inflammatory  process  involv-) 
ing  the  entire  generative  tract,  or  extending  beyond  it  to  the  parametriui 
or  peritonaeum,  and  sometimes  resulting  in  a  general  pyaemic  infection.     Ii 
other  cases  the  infectious  elements  pass  through  the  port  of  entry  with^ 
such  rapidity  that  they  do  not  excite  local  lesions,  but  produce  a  septicaemia 
which  is  rapidly  fatal — the  sepsis  foudroyante  of  the  French  authors.     In 
the  majority  of  cases  of  puerperal  infection,  however,  the  endometrium 
is  the  portion  affected,  and  the  morbid  process  does  not  pass  beyond  it,  the 
condition  being  termed  a  septic  or  putrid  endometritis,  according  as  it 
has  resulted  from  the  invasion  of  pyogenic  or  putrefactive  organisms  re- 
spectively. 

In  other  cases  the  lesions  may  be  situated  in  any  part  of  the  generative 
tract,  more  than  one  region  being  frequently  implicated.  Thus,  at  differ- 
ent times  we  have  to  deal  with  a  puerperal  vaginitis,  endometritis,  metritis^ 
parametritis,  metrolymphangitis,  metrophlebitis,  salpingitis,  oophoritis^ 
peritonitis,  pyaemia,  or  phlegmasia  alba  do-lens  respectively. 

Lesions  of  the  vulva  and  Vagina. — In  former  times  the  puerperal  ulczx. 
was  of  very  common  occurrence,  but  with  the  introduction  bf  aseptic  meth- 
ods into  midwifery  its  frequency  has  become  markedly  diminished,  so  that 
now  it  is  only  rarely  encountered. 

These  ulcers  appear  on  the  surface  of  tears  about  the  vulva  and  peri- 
naeum,  soon  take  on  a  dirty,  greenish-yellow  appearance  which  is  due  to 
necrosis,  and  are  bathed  in  a  foul-smelling  secretion.  In  some  cases  tbey 
are  covered  by  a  grayish-white  membrane,  and  on  this  account  were  for- 


PUERPERAL   INFECTION  7<::; 

merry  designated  as  "diphtheritic  ulcers."  Careful  kid  eric-logical  exami- 
nation, however,  has  shown  that,  except  for  their  external  appearance,  they 
haw  nothing  in  common  with  diphtheria.  As  a  rule  these  give  rise  to  very 
Little  systemic  disturbance,  and  would  frequently  pass  unnoticed  were  it 
not  for  ocular  inspection. 

Puerperal  Vaginitis. — Of  this  there  are  two  forms,  the  one  being  char- 
acterized by  ircneral  inflammation,  the  mucosa_becoming  thickened,  soft, 
reddened,  and  bathed  with  an  abundant  purulent  secretion.  In  the  other 
type,  especially  when  torn  surfaces  are  present,  the  vaginal  walls  may  be 
the  seat  of  a  pseudo-diphtheritic  membrane ,  which  may  vary  in  extent  from 
a  small  patch  covering  a  tear  to  a  complete  cast  of  the  entire  vaginal  canal. 

Until  recently  it  was  helieved  that  none  of  the  so-called  cases  of  diph- 
theria of  the  vagina  were  i\uc  to  the  invasion  of  the  Klebs-Loeffler  bacillus; 
but  the  recent  observations  of  Bumm,  Nisot,  myself,  and  others  show  that 
in  a  \'v\v  cases  that  organism  is  undoubtedly  the  ^etiological  factor. 

Endometritis. — The  tnosl  common  Lesion  in  puerperal  infection  is  an 
inflammation  oT  the  endometrium.  .When  one  recalls  the  condition  of  the 
^uterus  immediately  after  delivery,  with  its  bleeding,  raw  surfaces  and  the 
large,  gaping,  thrombosed  placental  sinuses,  it  becomes  apparent  that  any 
virulent  material  which  has  been  introduced  into  the  cavity  during  labour 
can  easily  find  entry  into  its  walls.  Again,  when  one  considers  the  mechan- 
ism by  which  the  decidua  is  normally  removed,  one  can  readily  see  that  an 
ideal  culture  medium  is  prepared  by  Nature  for  the  reception  and  propaga- 
tion of  organisms  introduced  from  without. 

In  puerperal  endometritis  the  infection  may  be  limited  to  the  placental 
site,  or  may  extend  over  the  entire  mucosa.     When  the  former  alone  is  i 
implicated,  the  organisms  are  usually  found  growing  into  the  thrombi  and  J 
producing  comparatively  little  local  reaction.     On  the  other  hand,  when  * 
the  entire  internal  surface  of  the  uterus  is  affected,  the  endometrium  may  I 
become  converted  into  a  stinking,  sloughing  area  made  up  of  necrotic  mate-   I 
rial  and  decidual  debris,  and  bathed  with  a  bloody,  purulent  discharge.     The 
necrotic  material  soon  takes  on  a  dirty  yellowish-green  appearance,  and  in 
many  instances  ulcerated  surfaces  appear,  coated  with  fibrin  and  presenting 
the  clinical  picture  of  diphtheria.     This  type  was  formerly  designated  as 
diphtheritic  endometritis,  but  just  as  happens  in  the  case  of  the  vagina,  the 
condition,  as  a  rule,  is  not  a  true  diphtheria,  but  simply  represents   a 
fibrinous  exudation,  the  result  of  an  intense  necrosis  following  the  invasion 
of   the   usual   pyogenic   organisms.      Infections    due    to   streptococcus    or 
staphylococcus  are  usually  associated  with  very  little  odour;  whereas  in  those 
excited  by  bacillus  coli  or  any  of  the  various  putrefactive  organisms  the 
interior  of  the  uterus  is  bathed  with  a  profuse  foul-smelling  discharge 
which  frequently  contains  gas  bubbles.     The  amount  of  necrotic  material 
produced  is  often  enormous,  and  may  recur  with  great  rapidity  after  curet- 
ting.    Fig.  623  represents  the  uterus  from  a  case  of  puerperal  infection 
due  to  streptococcus  and  bacillus  coli.     The  woman  succumbed  ten  days 
after  the  birth  of  the  child,  having  been  curetted  three  or  four  clays  before 
death,  the  uterus  at  that  time  having  been  scraped  perfectly  clean.     A 
glance  at  the  drawing,  however,  shows  that  the  entire  cavity  is  filled  with 


764 


OBSTETRICS 


necrotic  material,  which  in  all  probability  had  been  reproduced  in  the 
interval  elapsing  between  the  curettage  and  the  time  of  death. 

Although  the  infection  generally  remains  limited  to  the  endometrium, 
in  not  a  few  cases  it  may  progress  beyond  it,  giving  rise  to  a  metritis,  a 


Fig.  623. — Uterus  from  "Woman  Dying  Ten  Days  after  Labour  from  a  Mixed  Infection, 
with  Streptococcus  and  Bacillus  Coli.     X  %. 


lymphangitis,  or  a  phlebitis,  as  the  case  may  be.  This  extension  usually 
occurs  through  the  lymphatics,  and  in  such  cases  areas  of  inflammation  can 
be  traced  along  their  course  extending  to  the  peritoneal  surface  of  the 
uterus.  At  other  times,  especially  when  the  infection  has  been  limited  to 
the  placental  site,  the  thrombi  may  be  invaded  by  the  micro-organisms,  and 
there  results  a  phlghitis  which  may  remain  limited  to  the  uterine  wall  or  may 
rapidly  extend  beyond  it  and  give  rise  to  the  various  thrombotic  forms  of 
puerperal  infection. 

The  lesions  produced  in  the  endometrium  vary  considerably  according 
to  the  micro-organisms  concerned,  and  still  more  according  to  their  viru- 
lence. In  the  cases  in  which  one  has  to  deal  with  a  virulent  streptococ- 
cus or  staphylococcus  infection,  the  local  changes  are  comparatively  slight, 
the  process  rapidly  spreading  through  the  lymphatics  or  veins  past  the 
uterus,  and  giving  rise  to  a  peritonitis  or  a  general  systemic  infection.  On 
the  other  hand,  in  the  cases  due  to  putrefactive  organisms,  to  the  colon 


PUERPERAL   INFECTION 


7«;: 


bacillus,  and  to  the  ordinary  pus-organisms  of  lesser  virulence,  the  process 

remains  -e  or  less  limited  to  the  endometrium  and  causes  marked  local 

lesions.  Fig.  (\'i  I  represents  the  uterus  I'rom  a  woman  dying  of  a  virulent 
streptococcic  infection.  The  walls  of  its  cavity  are  seen  to  be  almost  per- 
fectly smooth,  and  nothing  is  present  which  could  have  been  removed  by 
means  of  the  curette.  In  this  respect  the  ease  stands  in  marked  contrast  to 
the  one  represented  in  Fig.  623,  in  which  the  infectious  agents  were  strep- 
tococcus and  bacillus  coli. 

Moreover,  when  one  studies  the  microscopical  features  of  puerperal 
endometritis,  one  finds  these  differences  still  further  accentuated.  Mosl 
of  our  knowledge  on  this  point  we  owe  to  the  researches  of  Bumm  and 
Doderlein,  both  of  whom  have  shown  that  there  are  marked  histological 


Fig.  624. — Uterus  from  Woman  Dying  Tex  Days  after  Labour  from  Streptococcus  Infec- 
tion.    X  %. 


differences  between  the  putrid  and  septic  forms.  According  to  Bumm,  in 
sections  through  the  Avail  of  a  uterus  the  seat  of  a  putrid  endometritis,  a  thick 
layer  of  necrotic  material  is  found  lining  the  uterine  cavity,  embedded  in 


766* 


OBSTETRICS 


which  are  large  numbers  of  the  offending  micro-organisms.  Beneath  this 
is  a  thick  laver  of  small -cell  infiltration — the  zone  of  reaction — and  under 
this  again,  more  or  less  normal  tissue.  Careful  study  of  the  sections 
shows  that  the  micro-organisms  are  limited  almost  entirely  to  the  superficial 


Fig.  625. — Pueepeeal  Endometritis  Due  to 
Colon  Infection,  showing  Maeked  De- 
velopment of  Leucocytic  Wall. 


Fig.  626. — Pueepeeal  Endometeitis  Due  to 
Streptococcus  Infection,  showing  Slight 
Development  of  Leucocytic  Wall. 


necrotic  layer;  and  although  a  few  may  be  present  in  the  reaction  zone. 
none  canlSeTnade  out  in  the  tissues  beneath  it,  thus  showing  Nature's 
mode  of  preventing  the  invasion  of  the  body  by  the  micro-organisms  (Figs. 
625  and  627). 

These  pictures  are  observed  not  only  in  the  cases  due  to  infection  with 
the  putrefactive  bacteria,  but  also  in  those  in  which  the  pyogenic  organ- 
isms possess  only  a  slight  degree  of  virulence.  On  the  other  hand,  in  cases 
of  septic  endometritis,  and  especially  where  the  organisms  are  virulent,  a 
totally  different  appearance  is  noted.  Although  here  also  a  layer  of  ne- 
crotic material  containing  organisms  is  found  adjoining  the  uterine  cavity, 
it  is  usually  thinner  than  in  the  preceding  case.  The  zone  of  small-cell 
infiltration  is  either  lacking  or  very  imperfectly  developed,  and  the  micro- 
organisms can  be  observed  making  their  way  down  through  the  decidua 
and  along  the  lymphatics  through  the  muscular  wall  of  the  uterus  out 
towards  its  peritoneal  surface  (Figs.  626  and  628).  I  have  been  able  to 
abundantly  confirm  the  observations  of  Bumm,  whose  conclusions  are  amply 
justified  (Plate  XVI). 

The  effect  produced  by  various  micro-organisms  was  strikingly  demon- 


feb 


PLATE   XVI. 


%*, 


%. 


» 


/& 


%• 


\CTc- 


"&.Ty/LT^*n\X.aJou^  ,-f  ec. 


SECTION  THROUGH   ENDOMETETUM  IN   STREPTOCOCCIC   PUERPERAL 
INFECTION.      X  1000. 


itki;i'i:i;.\l  infection 


— . .  — 


strated  in  one  of  my  nun  cases — a  double  infection  with  streptococcus  and 
bacillus  coli.  On  making  sections  through  the  uterine  wall  characteristic 
necrotic  tissue  was  seen  lining  the  cavity  of  the  uterus,  and  in  ii  ap- 
peared both  forms  of  micro-organisms.  Beneath  this  the  zone  of  small- 
eell  infiltratioD  was  fairly  well  developed,  and  in  its  upper  pari  both  forms 
of  organisms  were  recognisable.  In  its  lower  portion,  however,  there  wen- 
only  streptococci,  which  had  continued  to  pass  through  the  uterine  wall  by  | 
way  of  the  lymphatics,  and  on  reaching  the  peripheral  surface  had  given 
rise  tn  a  peritonitis. 

It  would  appear,  therefore,  that  Nature  endeavours  to  confine  the  micro-) 
organisms  to  the  inner  surface  of  the  uterus  by  interposing  between  thei 
necrotic  layer  and  the  deeper  portions  a  barrier  of  small-cell  infiltration,] 
which  acts  as  an  efficient  filter  when  the  micro-organisms  are  attenuated,) 
but  fails  to  restrain  them  when  they  possess  a  marked  degree  of  virulence. 

Parametritis. — One  of  the  more  frequent  complications  of  the  uterine 
infection  is  parametritis,  which  is  usually  due  to  the  transmission  of  the 


x  J  M 


fe^ 


¥. 


'''& 


■  J  .■   ■&_  ft  ^^r-** 


T^  * 


f - 


mmkM  .  v 

Fig.  627. — Colon  Bacillus  Endometritis. 
Leccocytic  Wall  not  Invaded  bt  Bac- 
teria.    X  800. 


Fig.  628. — Streptococcic  Endometritis,  show- 
ing Invasion  of  Leukocytic  Wall.  X 
800. 


micro-organisms  through  the  lymphatics  to  the  peri-uterine  connective  tis- 
sue. The  first  effect  of  their  invasion  is  a  marked  inflammatory  oedema, 
with  very  little  or  no  suppuration.    In  mild  cases  the  process  goes  no  fur- 


768  OBSTETRICS 

ther,  but  in  the  severer  types  it  rapidly  spreads  to  the  surrounding  connect- 
ive tissue  and  eventuates  in  abscess  formation.  The  infectious  agents  in 
severe  cases  follow  the  course  of  the  lymphatics,  and  sometimes  pass 
behind  the  peritonaeum  and  give  rise  to  retroperitoneal  phlegmons,  which 
may  extend  as  high  as  the  posterior  mediastinum.  On  the  other  hand, 
when  they  are  transmitted  along  those  which  go  to  the  anterior  portion 
of  the  pelvis,  inflammatory  phenomena  occur  about  the  inguinal  canal. 
In  still  another  class  of  cases  they  invade  the  connective  tissue  surround- 
ing the  greater  vessels  of  the  thigh,  and  give  rise  to  a  phlegmasia  alba 
dolens. 

Occasionally  the  parametritic  implication  originates  from  infected  tears 
about  the  cervix,  but  as  a  rule  it  is  secondary  to  infection  from  the  uterine 
cavity. 

As  has  already  been  pointed  out,  in  a  considerable  number  of  cases 
the  inflammatory  process  extends  into  the  uterine  wall,  and  there  gives 
rise  to  divers  lesions  of  metritis,  which  may  vary  from  small  areas  of 
leucocytic  infiltration  to  definite  abscess  formation.  As  a  rule,  how- 
ever, multiple  abscesses  scattered  through  the  uterine  wall  are  due  to 
implication  of  the  lymphatics,  and  inasmuch  as  these  channels  are  most 
numerous  beneath  its  peritoneal  covering,  abscesses  are  most  abundant  in 
that  situation. 

Salpingitis. — In  a  small  proportion  of  cases  the  process  extends  direct- 
ly from  thTuterine  cavity  to  the  Fallopian  tubes,  and  there  gives  rise  to 
various  inflammatory  phenomena.  Occasionally  the  salpingitis  is  due  to 
infection  through  the  lymphatics  and  not  by  continuity  from  the  endome- 
trium. Sometimes  an  oophnritj^  occurs,  the  ovaries  being  enlarged  to  sev- 
eral times  their  usual  size  and  very  cedematous.  The  process  may  stop  here 
or  go  on  to  typical  abscess  formation.  The  ovarian  infection  in  the  ma- 
jority of  cases  is  due  to  lymphatic  involvement,  and  is  usually  associated 
with  affections  of  the  parametrium.  Much  more  rarely  it  results  from 
direct  infection  of  a  ruptured  follicle  by  means  of  the  peritonitic 
fluid. 

Peritonitis. — In  the  vast  majority  of  cases  the  fatal  termination  in  puer- 
peral infection  is  due  to  a  peritonitis.  As  was  pointed  out  when  consider-  j 
ing  the  histological  changes  in  puerperal  endometritis,  the  streptococci  or 
other  infecting  agents  may  rapidly  make  their  way  from  the  interior  of 
kthe  uterus  to  the  peritoneal  surface  by  means  of  the  lymphatics,  and  there 
'give  rise  to  inflammatory  changes.  This  is  the  usual  mode  of  infection, 
/but  in  rare  instances  it  may  be  due  to  the  escape  of  pus  from  the  Fallopian 
ytubes;  though  in  none  of  the  autopsies  which  the  writer  has  witnessed  upon 
women  dead  of  puerperal  fever  has  such  a  mode  of  origin  been  observed. 
In  other  cases,  it  may  follow  the  rupture  of  a  parametritic  or  ovarian 
\abscess. 

'  J^yosniia. — The  pysemic  form  usually  results  from  the  infection  of 
thrombi  at  the  placental  site  and  the  subsequent  inflammatory  changes 
occurring  in  the  veins.  The  thrombosis  may  be  limited  to  a  comparatively 
small  area  and  be  entirely  within  the  uterine  wall,  or  it  may  extend  beyond 
the  uterus,  so  that  occasionally  all  the  pelvic  vessels  are  thrombosed  as 


PUEUPKKAIi    INFECTION  769 

Ear  up  as  the  junction  of  the  renal  veins  wit  1 1  t lie  inferior  vena  cava.  By 
the  breaking  clown  of  the  thrombi  small  particles  escape  into  the  circulation 
and  are  carried  by  the  blood  current  in  various  directions,  giving  rise  to 
endocarditis  and  nietaslalic  abscesses,  from  which  no  portion  of  the  body  ap- 
pears to  be  exempt.  In  this  form  of  puerperal  infection  such  absce.-se-  may 
be  found  in  any  of  the  internal  organs,  the  synovial  surfaces  also  being  fre- 
quently implicated  and 
giving  rise  to  spelling*: 
about  the  joints,  which,  y 

if  not  promptly  treated,       ,   N       &  '~~~JL^    "•    ^      \^<  3- 
may  lead  to  their  com-      "*,  ->*&>■ 

plete  destruction.  *   '* 

In  a  number  of 
other  cases  blebs  or 
bullae,  due  to  the  same 
cause,  appear  on  vari- 
ous portions  of  the 
body,  and  in  their  con- 
tents the  offending  mi- 
cro-organisms are  read-  n    _  _  „        "*^-^ 

.  °  Fig.  629. — Section  throvgh  Thrombosed   1jelvic   vein, 

lly  demonstrable.     Most  showing  Streptococci.     X  800. 

cases  of  pyaemia  present 

very  little  uterine  involvement,  and  deaths  wh  en  it  occurs,  is  due  to  gen- 

eral  exhaustion  following  a  prolonged  suppurative  process,  rather  than 

to  peritonitis,  which  is  the  usual  cause  of  death  in  the  other  forms  of 

infection. 

Phlegmasia  Alba  Dolens. — As  was  pointed  out  when  the  question  of  para- 
metritis was  considered,  this  affection  is  sometimes  due  to  the  extension 
through  the  lymphatics  of  a  parametritis  to  the  tissues  surrounding  the 
great  vessels  of  the  thigh.  As  a  rule,  however,  it  results  from  the  extension 
of  a  thrombotic  process  from  the  pelvic  veins,  though  sometimes  it  appears 
to  be  the  only  manifestation  of  the  infection,  and  under  such  circumstances 
its  mode  of  production  is  very  difficult  to  explain.  In  a  small  percentage 
of  cases  it  is  possibly  not  of  infectious  origin. 

JEtiology. — Careful  investigation  has  demonstrated  that  the  bacteria 
concerned  in  puerperal  infection  are  identical  with  those  with  which  we  are 
familiar  as  causing  wound  infection.  In  fact,  puerperal  infection  must  be 
regarded  as  a  wound  infection  caused  by  the  introduction  of  pathogenic 
organisms  into  the  generative  tract  either  before,  during,  or  immediately 
after  labour.  In  other  words,  we  have  to  deal  with  a  direct  infection  from 
without,  the  offending  bacteria  being  brought  to  the  woman  by  the  hands, 
instruments,  or  any  other  object  which  may  come  in  contact  with  her  gen- 
erative organs. 

Puerperal  infection,  then,  is  contact  infection,  this  conception  having 
been  first  definitely  enunciated  by  Semmelweiss  in  the  following  words: 
"  I  consider  puerperal  fever,  not  a  single  case  excepted,  as  a  resorption 
fever,  caused  by  the  resorption  of  a  decomposed  animal-organic  material. 
The  first  result  of  the  absorption  is  a  change  in  the  blood,  and  the  exuda- 
50 


770  OBSTETRICS 

tions  are  the  result  of  this  change.  The  decomposed  animal-organic  ma- 
terial, which  when  resorbed  causes  childbed  fever,  is  brought  to  the  indi- 
vidual from  without  in  the  great  majority  of  cases,  and  this  is  infection 
from  without.  These  are  the  cases  which  represent  the  epidemics  of  child- 
bed fever.    These  are  the  cases  which  can  be  prevented." 

In  the  latter  part  of  the  eighteenth  century  puerperal  fever  began  to 
be  considered  as  a  contagious  malady  in  England.  This  conception  appar- 
ently originated  with  Thomas  Kirkland,  of  Ashby,  in  1774,  but  was  first 
clearly  enunciated  in  1795  by  Gordon,  of  Aberdeen,  in  his  treatise  "  On  the 
Epidemic  of  Puerperal  Fever,  as  it  prevailed  in  Aberdeen  from  December 
1789  to  March  1792,"  in  which  he  gave  a  table  of  77  cases  which  he  had 
attended  himself. 

In  this  country  we  are  mainly  indebted  to  Oliver  Wendell  Holmes  for 
introducing  the  conception  of  the  infectious  nature  of  the  affection.  In 
an  article  entitled  Puerperal  Fever  as  a  Private  Pestilence,  first  published 
in  1813,  he  clearly  showed  that  it  was  a  preventible  affection,  and  owed  its 
origin  either  to  the  accoucheur  or  midwife.  His  teachings,  however,  did  not 
exert  the  influence  which  might  have  been  expected,  mainly  because  the}r 
were  opposed  by  the  leading  obstetricians  of  the  country,  notably  Meigs  and 
Hodge,  the  former  stating  that  he  preferred  to  consider  the  disease  as  due 
to  the  workings  of  Providence,  which  he  could  understand,  rather  than  to 
an  unknown  infection  of  which  he  could  form  no  conception. 

For  many  years  the  prevalent  theory  in  Europe  as  to  the  causation  of 
puerperal  fever  was  that  it  was  due  to  miasmatic,  telluric,  or  atmospheric- 
influences.  This  view  held  its  ground  until  after  the  appearance  of  Semmel- 
weiss's  article  in  1861;  although  in  1864,  Hirsch,  after  studying  the  matter 
from  an  historical  standpoint,  came  to  the  conclusion  that  the  malady  was 
of  infectious  rather  than  of  miasmatic  origin. 

It  was  not,  however,  until  Lister  had  introduced  antiseptic  methods  into 
surgery,  and  Stadfeld,  of  Coj)enhagen,  had  recommended  the  use  of  bichlo- 
ride of  mercury  in  obstetrics,  that  the  great  mass  of  the  profession  began 
to  understand  that  puerperal  fever  was  due  to  contact  infection,  and  could 
be  prevented  to  a  very  great  degree.  The  bacteriological  work  of  Pasteur 
and  his  successors,  and  the  almost  constant  presence  of  streptococci  in  fatal 
cases,  decided  the  question,  and  at  present  no  one  doubts  the  infectious 
nature  of  the  disease. 

Modes  of  External  Infection. — The  most  usual  mode  of  infection  is  bv 
the  liandsof  the ^obstetrician  or  the  midwife,  and  no  one  who  has  observed 
the  way  in  which  not  a  few  medical  men  conduct  labours  can  wonder  that 
puerperal  fever  occasionally  occurs.  The  employment  of  dirty  instru- 
ments, as  well  as  of  dirty  hands,  also  plays  an  important  part- 
Sources  of  infection,  much  rarer,  it  is  true,  but  generally  overlooked, 
are  copulation  during  the  later  days  of  pregnancy,  and,  especially  among 
the  lower  classes,  self -inoculation  by  the  patient  fingering  her  genitalia  or 
even  making  internal  examinations!  Contact  with  secretions  from  wonnrls 
of  any  kind  also  plays  an  important  part  in  its  production,  and  whether 
the  purulent  material  be  from  an  external  wound  or  elsewhere  within  the 
body,  the  result  will  be  the  same.     It  is  only  necessary  to  recall  in  this 


PUERPERAL  INFECTION  771 

connection  the  case  of  Dr.  Untter,  of  Philadelphia,  who  was  followed  wher- 
ever lie  went  by  an  epidemic  of  puerperal  fever,  while  his  brother  practi- 
tioners \\rvr  practically  free  from  it.  11  appeared  later  thai  the  source  of 
infection  was  an  ozaena  from  which  he  was  constantly  contaminating  his 
hands. 

Wounds  on  the  hands  of  the  nurse,  bone  felons,  and  other  affections 
of  the  lingers,  and  not  infrequently  a  pustular  eczema,  are  sometimes  re- 
sponsible. 

For  many  years  it  has  been  known  that  puerperal  fever  often  occurred 
when  a  woman  in  labour  was  cared  for  by  a  physician  who  at  the  same 
time  was  attending  a  case  of  erysipelas.  As  has  already  been  said,  one  of 
the  old  ideas  concerning  the  affection  held  it  to  be  identical  with  the  former 
disease,  but  it  was  not  until  bacteriology  had  proved  that  erysipelas  and 
most  of  the  serious  cases  of  puerperal  infection  are  due  to  the  strepto- 
coccus that  this  relation  was  understood.  At  the  present  time  the  ma- 
jority of  observers  believe  that  there  is  no  essential  difference  between 
streptococcus  erysipelatis  of  Fehleisen  and  the  ordinary  streptococcus 
pyogenes. 

Puerperal*  fever  has  also  been  frequently  observed  to  occur  in  the 
practice  of  those  attending  diphtheria,  scarlet  fever,  and  occasionally 
typhoid  cases.  Although  no  essential  relationship  between  these  affections 
has  ever  been  proven,  it  is  well  known  that  in  both  diphtheria  and  scarlet 
fever  complications  due  to  the  streptococcus  are  frequently  met  with,  and 
these  organisms  may  be  conveyed  to  the  woman  in  labour. 

Air  infection  is  supposed  by  some  to  play  an  important  setiological  part, 
and  many  authors  advise  covering  the  external  genitalia  with  an  occlusive 
pad  to  prevent  the  entry  of  air  into  the  vagina,  and  thus  eliminate  this 
source  of  infection.  This,  however,  occurs  very  infrequently,  if,  indeed, 
it  is  ever  the  cause  of  the  disease;  nor  are  the  statements  of  Garrigues  con- 
vincing, in  which  he  attributed  an  epidemic  of  puerperal  fever  in  the  ISTew 
York  Lying-in  Hospital  to  the  presence  of  a  dead  rat  in  the  cellar,  inasmuch 
as  it  is  far  more  probable  that  the  disease  was  due  to  imperfect  hand  disin- 
fection on  the  part  of  his  assistants,  or  to  the  introduction  of  pathogenic 
organisms  within  the  vagina  in  some  way  or  other  by  the  patients  them- 
selves. Nevertheless,  in  England,  and  to  a  less  extent  in  this  country. 
smver  c/as  is  believed  to  play  a  prominent  part  in  the  production  of  puerperal 
infection.  But  I  believe  that  the  clanger  of  infection  from  such  sources  has 
been  greatly  exaggerated,  and  will  be  spoken  of  less  and  less  frequently  as 
medical  men  become  better  versed  in  the  technique  of  rigorous  hand  dis- 
infection. 

To  show  how  accurate  a  conception  Semmelweiss  possessed  of  the  vari- 
ous modes  of  contact  infection,  it  may  be  interesting  to  quote  what  he 
says  concerning  it:  "The  bearer  of  the  decomposed  animal-organic  mate- 
rial is  the  examining  finger,  the  operating  hand,  instruments,  bedclothes, 
atmospheric  air,  sponges,  the  hands  of  miclwives  or  nurses  which  come  in 
contact  with  the  excrement  of  women  sick  with  puerperal  fever,  and  after 
that  handle  pregnant  or  parturient  women.  In  other  words,  the  bearer  of 
the  decomposed  animal-organic  material  is  anything  which  is  soiled  by  a 


772  OBSTETRICS 

decomposed  animal-organic  material  and  comes  in  contact  with  the  genitalia 
of  these  patients." 

Auto-infection. — Ever}'  one  at  the  present  time  believes  that  the  vast 
majority  of  cases  of  infection  are  the  result  of  the  introduction  from  with- 
out of  pathogenic  micro-organisms  into  the  genital  canal  of  the  pregnant 
or  parturient  woman.  Nevertheless,  many  authorities  teach  that  in  a  cer- 
tain number  of  cases  the  infection  does  not  result  in  this  manner,  but  owes 
its  origin  to  micro-organisms  which  were  already  within  the  genital  tract 
before  the  onset  of  labour.  To  infection  arising  in  this  way  the  term 
"  auto-infection  "  is  applied.  The  conception  originated  with  Semmelweiss, 
who  stated:  "  In  rare  cases  the  decomposed  animal-organic  material,  which 
causes  childbed  fever  when  absorbed,  is  produced  within  the  patient  herself. 
These  are  the  cases  of  auto-infection,  and  cannot  be  prevented." 

With  the  enthusiasm  which  attended  the  introduction  of  antiseptic 
methods  of  midwifery,  the  possibility  of  auto-infection  was  lost  sight  of  for 
a  time,  and  it  was  only  when  the  statistics  of  well-conducted  lying-in  estab- 
lishments showed  that  a  certain  number  of  cases  of  infection  still  occurred, 
despite  the  rigorous  application  of  antiseptic  principles,  that  the  idea  was 
rehabilitated  hv  Ahlfeld  and  Kaltenbach. 

Of  course,  with  the  recognition  of  the  fact  that  puerperal  fever  was  a 
germ  disease,  the  definition  introduced  by  Semmelweiss  fell  to  the  ground, 
since  the  micro-organisms  could  not  originate  spontaneously  within  the 
body  of  the  woman.  Kaltenbach  then  advanced  the  view  that  pathogenic 
organisms  are  present  in  the  vaginae  of  a  considerable  number  of  healthy 
pregnant  women,  and  that  these  might  be  introduced  into  the  uterus  by  a 
finger  which  was  perfectly  sterile  before  being  passed  up  the  canal.  Of 
course  these  would  not  be  instances  of  auto-infection  in  the  strict  sense 
of  the  word,  and  much  confusion  might  have  been  avoided  had  the  term 
"  indirect  infection "  been  substituted  for  it,  since  the  micro-organisms 
must  have  been  introduced  into  the  vagina  at  some  period  of  life,  and  the 
question  simply  resolves  itself  into  one  of  time.  Many  observers  now  hold 
that  auto-infection,  even  in  this  modified  sense,  is  not  possible,  and  that  all 
cases  of  puerperal  infection  are  due  to  the  introduction  from  without  of 
pathogenic  micro-organisms  at  the  time  of  labour. 

After  all,  the  question  can  be  finally  decided  only  by  the  results  of  the 
bacteriological  examination  of  the  generative  tract  in  the  pregnant  and  non- 
pregnant conditions.  If  careful  investigation  shows  that  pathogenic  micro- 
organisms are  absent  from  the  uterus  and  vagina  of  the  pregnant  woman, 
the  doctrine  of  auto-infection  must  be  abandoned.  On  the  other  hand, 
if  they  can  be  demonstrated  in  apparently  healthy  women  during  preg- 
nancy, despite  any  preconceived  opinion,  we  shall  be  forced  to  admit  its 
possibility. 

Practically  all  bacteriological  investigators  are  united  in  claiming  that 
the  cavity  of  the  norm?!  ntfvnis  is  free  from  micro-organisms  both_in__iIi£ 
pregnant  and  non-pregnant  r.rmditi'pn<^  This  fact  has  been  amply  proved 
by  the  work  of  Gonner,  Doderlein,  and  Wrnternitz;  while  Strauss  and 
Sanchez-Toledo  have  demonstrated  the  same  in  the  lower  animals.  On  the 
contrary,  Franz  and  Burckhardt  state  that  bacteria  can  be  isolated  from 


PUERPERAL    INFECTION 


773 


the  cavity  of  tin-  uterus  in  the  latter  pari  of  the  puerperium  in  a  large 
proporl  Ion  of  cases.  Their  results,  however,  are  controverted  by  t  lie  recenl 
work  of  Doderlein  and  Winternitz,  and  appear  invalidated  by  the  fact  thai 
the  writer  found   the   uterine   lochia  absolutely  sterile  in  25  out  of    L50 

women  who  presented  rise-  of  temperature  in  the  piiei-perium. 

On  the  other  hand,  when  we  come  to  consider  the  bacterial  contents 
of  the  cervical  canal  in  the  healthy  woman,  the  conclusions  are  by  no 
means  so  uniform.  Some  observers  state  that  micro-organisms  are  pres- 
ent  in  mo-1  cases,  whereas  others  consider  that  they  are  usually  absent. 
These  contradictory  results  were  apparently  satisfactorily  reconciled  by 
Wall  hard's  work.  He  found  that  cultures  taken  from  the  lower  portion 
of  the  cervical  canal  contained  identically  the  same  micro-organisms  as  the 
vagina,  but  that  they  became  less  plentiful  as  the  internal  os  was  ap- 
proached, disappearing  altogether  about  one  third  of  the  way  up.  It  would 
appear,  therefore,  that  the  observers  who  found  bacteria  in  the  cervix  had 
obtained  the  secretion  from  the  lower  portion  of  its  canal,  while  those  who 
reported  negative  results  had  examined  material  from  higher  up.  Accord- 
ingly, we  may  conclude  that  both  the  uterus  and  upper  portion  of  the 
cervix  are  practically,  if  not  absolutely,  sterile,  and  can  therefore  offer  no 
possible  chance  for  the  occurrence  of  either  auto-  or  indirect  infection. 

Ultimately  the  question  narrows  down  to  the  demonstration  of  the  pres- 
ence or  absence  of  pathogenic  micro-organisms  in  the  healthy  vagina, 
and.  according  to  the  results  of  careful  investigations  on  these  lines,  the 
doctrine  of  auto-infection  must  be  generally  accepted  or  absolutely  aban- 
doned. Ahlfeld,  in  all  his  articles  upon  the  subject,  assumes  that  "the 
vagina  is  swarming  with  various  varieties  of  pathogenic  organisms,"  and 
auto-infection  can  only  be  prevented  by  thoroughly  disinfecting  the  vagina 
in  every  case  by  antiseptic  douches. 

Unfortunately,  the  bacteriological  examination  of  the  vaginal  secretion 
of  pregnant  women  until  recently  did  not  offer  grounds  for  absolutely 
satisfactory  conclusions.  Thus,  the  work  of  Gonner,  Thomen,  Sam-chin. 
Kronig  and  jfenge,  Bensis,  Bergholm,  and  the  writer  in  1898,  appear  to 
show  that  pyogenic  micro-organisms,  with  the  exception  of  the  gonococ- 
cus,  cannot  be  found  in  the  vagina  of  pregnant  women;  while,  on  the  other 
hand,  numerous  investigators  have  isolated  the  streptococcus  in  a  varying 
proportion  of  their  cases,  as  is  shown  by  the  following  table: 


Burckhardt 4$ 

Steffeck 4£ 

Doderlein 4.1$ 

Burguburu 8.5$ 

Koblanek 9.5$ 

Vahle 10$ 


Witte 12.5$ 

Kottmann 13$ 

Winter 15$ 

Williams  (1893)....  20$    - 

Vahle 25$ 

Walthard 27$ 


Doderlenr's  studies  on  the  vaginal  secretion,  published  in  1892,  prom- 
ised for  a  time  to  reconcile  the  conflicting  results.  He  pointed  out  that 
the  vaginal  secretion  might  occur  in  one  of  two  forms,  which  he  designated 
as  normal  and  pathological.  The  former  was  a  thick,  dry,  cheese-like  ma- 
terial of  a  whitish  colour  and  distinctly  acid  reaction.     ^Microscopically  it 


774  OBSTETRICS 

showed  epithelial  cells,  a  pure  culture  of  tolerably  long  bacilli,  and  now  and 
then  a  few  yeast  fungi.  It  did  not  contain  pyogenic  micro-organisms,  and 
offered  absolutely  no  support  for  the  doctrine  of  auto-infection.  The  patho- 
logical secretion,  on  the  other  hand,  was  fluid,  generally  of  a  yellowish  colour 
suggesting  pus,  and  occasionally  contained  gas  bubbles.  In  it  were  found 
large  numbers  of  leucocytes,  many  micro-organisms  of  various  kinds,  and  in 
a  few  cases  streptococci.  Its  reaction  was  less  acid  than  that  of  the  normal 
secretion,  occasionally  neutral,  and  very  rarely  even  alkaline. 

Doderlein's  work  was  based  upon  the  examination  of  190  pregnant 
women,  55.3  per  cent  of  whom  presented  a  normal  and  41.6  per  cent  a 
pathological  secretion,  while  in  10  per  cent  of  the  latter  he  was  able  to 
demonstrate  the  presence  of  streptococci  by  cultural  methods.  His  inves- 
tigations, accordingly,  indicated  that  auto-infection  was  out  of  the  ques- 
tion when  the  secretion  was  normal,  whereas  its  occurrence  was  theoret- 
ically possible  in  10  per  cent  of  the  pathological  cases. 

Doderlein  supposed  that  the  contradictory  results  of  previous  investi- 
gators could  be  reconciled  by  assuming  that  those  obtaining  negative  re- 
sults had  worked  with  normal,  whereas  the  positive  results  were  obtained 
from  the  pathological  secretion. 

Kronig,  in  1897,  stated  that  he  had  examined  the  vaginal  secretion  in 
167  pregnant  women,  and  that  in  none  of  them  was  he  able  to  demon- 
strate typical  streptococci  nor  any  other  pyogenic  micro-organisms,  with 
the  excej)tion  of  the  gonococcus.  He  therefore  concluded  that  the  vaginal 
secretion  should  be  considered  as  practically  sterile,  and  that  it  did  not 
offer  the  slightest  evidence  in  support  of  the  doctrine  of  auto-infection. 
He  surmised  that  the  conflicting  results  of  the  various  observers  were  due 
to  differences  in  the  methods  of  obtaining  the  specimens,  and  that  when- 
ever the}r  were  obtained  by  means  of  a  speculum,  pathogenic  micro-organ- 
isms had  probably  been  carried  up  along  with  the  instrument  from  the 
vulva.  To  avoid  this,  he  recommended  the  employment  of  a  small  tube, 
which  could  be  introduced  into  the  vagina  under  the  guidance  of  the  eye, 
without  coming  in  contact  with  the  labia  minora  or  the  margins  of  the 
hymen. 

In  1898,  I  reported  to  the  American  Gynaecological  Society  the  results 
of  the  examination  of  the  vaginal  secretion  in  92  pregnant  women,  the 
specimens  having  been  obtained  by  means  of  a  small  tube  similar  to  that 
emploj^ed  by  Kronig  and  Menge.  In  none  of  these  cases  was  Streptococcus 
pyogenes  or  Staphylococcus  aureus  demonstrated,  but  in  6  cases  Staphylo- 
coccus epidermidis  albus  was  present.  Whether  the  latter  really  existed  in 
the  vagina,  or  whether  its  presence  was  due  to  contamination  is  open  to 
doubt;  but  as  this  organism  is  never  found  in  severe  cases  of  puerperal  infec- 
tion, its  presence  in  the  vaginal  secretion  is  a  matter  of  indifference  so 
far  as  the  question  in  dispute  is  concerned.  My  researches,  therefore,  con- 
firmed Kronig's  observations  as  to  the  absence  of  pyogenic  cocci  from  the 
vaginal  secretion  of  pregnant  women,  and  warranted  the  conclusion  that 
auto-infection  due  to  them  was  impossible,  although  it  could  not  be  absor 
iutely  denied  that  it  might  occasionally  occur  from  other  bacteria,  espe- 
cially in  some  of  the  cases  of  putrefactive  endometritis. 


PUERPERAL   INFECTION  7  7.". 

These  conclusions  wen'  absolutely  contradictory  to  those  at  which  I 
had  arrived  five  years  previously,  when  I  confirmed  Ddderlcin's  original 
work,  by  finding  streptococci  in  20  per  cenl  of  the  vaginal  secretions  which 

I  examined.  The  only  possible  explanation  for  the  different  results  ob- 
tained in  the  two  series  of  investigations  must  he  sought  in  the  manner 
in  which  the  specimens  were  obtained,  as  all  the  other  condition-  under 
which  the  work  was  carried  out  were  identical.  In  the  fir-t  series  .1 
sterile  glass  speculum  was  employed  in  obtaining  the  secretion,  and  in  the 
second  a  Menge  tube.  It  appeared  highly  probable  that  a  number  of  bac- 
teria were  carried  into  the  vagina  by  the  speculum  from  the  margins  of  the 
hymen  and  the  inner  surfaces  of  the  labia  minora  with  which  it  had  come 
in  contact;  whereas,  such  eon  tact  having  been  avoided  when  the  tube  was 
employed,  the  secretion  obtained  was  absolutely  free  from  contamination. 

The  truth  of  this  explanation  was  placed  beyond  doubt  by  the  examina- 
tion of  25  additional  cases.  3  sets  of  cultures  being  made  from  each.  The 
first  was  taken  from  the  hymen  and  inner  surfaces  of  the  labia  minora, 
the  second  from  the  vaginal  secretion  obtained  by  a  Menge  tube,  and 
the  third  from  the  vaginal  secretion  obtained  through  a  sterilized  specu- 
lum. Pyogenic  cocci  or  colon  bacilli  were  demonstrated  in  80  per  cent  of 
the  first,  in  none  of  the  second,  and  in  48  per  cent  of  the  third  series  of 
experiments,  thereby  showing  conclusively  that  the  vaginal  secretion  of 
healthy  women  is  absolutely  free  from  pyogenic  cocci  when  obtained  with- 
out contamination,  but  that  bacteria  are  present  upon  the  hymen  and 
labia  minora  in  most  cases,  and  that  it  is  impossible  to  introduce  a  specu- 
lum into  the  vagina  without  carrying  them  along  with  it  in  at  least  one 
half  of  such  cases. 

As  a  result,  therefore,  of  the  work  of  Kronig  and  Menge  and  myself. 
it  has  been  fairly  satisfactorily  demonstrated  that  under  normal  condi- 
tions pyogenic  cocci  are  never  present  in  the  vagina  of  pregnant  women. 
and  that  therefore  there  is  no  possibility  of  auto-infection  as  far  as  these 
organisms  are  concerned,  and  whenever  they  are  demonstrated  in  the 
uterine  secretion  of  puerperal  women  they  should  be  regarded  as  affording 
conclusive  evidence  of  external  infection.  It  is  possible,  however,  that  in 
rare  cases  auto-infection  mar  occur  from  certain  anaerobes  contained  in 
the  vaginal  secretion,  but  satisfactory  evidence  cannot  be  adduced  in  sup- 
port of  such  an  occurrence  until  methods  have  been  devised  which  will 
enable  us  to  isolate  and  grow  satisfactorily  in  pure  culture  the  organisms 
in  question. 

So  far  as  is  known,  the  gonococcus  is  the  only  pyogenic  bacterium  which 
can  live  and  thrive  in  the  vaginal  secretion.  But.  although  it  is  not  infre- 
quently the  cause  of  an  elevation  of  temperature  during  the  puerperium. 
such  cases  should  not  be  considered  as  supporting  the  doctrine  of  auto- 
infection,  for  the  reason  that  the  women  had  become  infected  before  or 
during  pregnancy,  and  the  organisms  had  persisted  in  the  crypts  of  the 
cervical  canal,  living  there  as  parasites,  and  simply  finding  more  suitable 
conditions  for  development  in  the  first  few  days  of  the  puerperium,  when 
they  make  their  way  into  the  uterine  cavity  and  manifest  their  presence 
by  the  production  of  fever  and  increased  discharge. 


776  OBSTETRICS 

An  interesting  fact  in  connection  with  the  question  of  anto-infection 
is  that  those  who  believe  most  firmly  in  its  possibility,  and  who  are  in 
the  habit  of  employing  prophylactic  vaginal  douches  for  the  destruction 
of  the  organisms  in  the  vagina,  have  thus  far  been  able  to  present  far  less 
favourable  statistics  than  their  opponents.  Thus,  Ahlfeld  finds  that  38 
per  cent  of  his  patients  have  a  rise  of  temperature  during  the  puerperium, 
even  after  the  use  of  the  prophylactic  douche.  Again,  Kaltenbach,  while 
chief  of  the  Lying-in  Clinic  at  Halle,  always  resorted  to  its  routine  em- 
ployment, but  the  statistics  show  a  very  material  improvement  since  his 
successor,  Fehling,  discontinued  the  practice.  Furthermore,  the  results  of 
Leopold  and  Hermann,  who  do  not  use  the  douche  at  all,  show  a  constant 
improvement  corresponding  with  the  increasing  precision  with  which  ob- 
jective asepsis  is  carried  out. 

The  value  of  the  prophylactic  vaginal  douche  has  recently  been  inves- 
tigated by  Kronig  and  Bretschneider.  The  latter  followed  2,280  cases- in 
the  Leipzig  clinic,  every  alternate  woman  being  douched.  The  puerperium 
was  febrile  in  45.18  per  cent  of  the  cases  in  which  the  douche  was  used,  as 
compared  with  36.78  per  cent  of  the  cases  in  which  it  was  omitted. 

Jewett  quotes  the  opinions  of  a  number  of  American  obstetricians  upon 
the  subject,  and  it  would  appear  that  the  majority  of  them  do  not  employ 
the  prophylactic  douche,  and  that,  while  a  certain  number  theoretically 
believe  in  auto-infection,  they  practically  act  as  if  its  occurrence  were 
impossible. 

Frequency. — It  is  very  difficult  to  make .  accurate  statements  as  to  the 
frequency  of  puerperal  infection,  especially  when  it  occurs  outside  of  hos- 
pital practice.  Concerning  this  condition  the  vital  statistics  of  the  health 
officers  of  the  various  cities  are  of  no  value,  inasmuch  as  the  vast  majority 
of  deaths  from  this  disease  are  reported  as  being  due  to  malaria,  typhoid 
(fever,  pneumonia,  or  other  causes. 

Thus,  Eeynolds,  in  1893,  wrote  an  article  upon  the  prevalence  of  puer- 
peral fever  in  Boston.  In  that  year  he  himself  had  seen  28  cases  in  hospital 
practice  with  7  deaths;  but,  in  looking  over  the  statistics  furnished  by  the 
health  office,  he  found  that,  granting  the  reports  of  the  department  to  be 
accurate,  this  number  represented  more  than  one  fourth  of  all  the  cases 
of  this  character  in  Boston — a  conclusion  which  would  certainly  appear 
incredible. 

Since  the  introduction  of  antiseptic  methods  into  midwifery,  the  mor- 
tality from  puerperal  infection  has  decreased  very  markedly  in  hospital 
practice.  In  the  old  Maternity  of  Paris,  and  in  the  Lying-in  Hospital  in 
Vienna,  in  some  years  the  mortality  from  this  affection  varied  from  10  to 
15  per  cent  of  all  the  women  admitted,  so  that  finally  it  attracted  the 
attention  of  the  public  at  large,  and  steps  were  being  taken  to  abolish 
such  institutions  as  a  menace  to  public  health.  With  the  introduction  of 
aseptic  methods,  however,  all  this  was  changed,  so  that  at  present  in  well- 
regulated  lying-in  hospitals  the  mortality  from  infection  is  usually  only  a 
small  fraction  of  1  per  cent.  Hence  it  happens  that  at  the  present  time, 
in -the  discussions  upon  the  subject,  at  least  so  far  as  hospitals  are  con- 
cerned, the  question  is  not  so  much  one  of  mortality,  but  mainly  one 


ITKKI'KRAL   INFECTION  iVi 

of  morbidity,  and  deals  with  the  percentage  of  patients  whose  temperature 
rises  above  US    ( '.  or  loo.  I     V.  during  tin-  puerperium. 

On  the  other  hand,  in  private  practice  it  is  doubtful  whether  the 
results  are  materially  better  to-day  than  they  were  before  the  introduc- 
tion of  antiseptic  methods,  I'tn-  the  reason  that  the  doctrines  of  asepsis  have 
not  yet  permeated  the  rank  and  file  of  medical  men,  much  less  of  mid- 
wives,  to  whose  care  is  committed  a  yery  large  proportion  of  obstetrical 
cases.  Though,  at  the  same  time,  it  must  he  admitted  that  we  rarely  hear 
of  outbreaks  of  puerperal  infection  such  as  are  mentioned  in  the  histori- 
cal work  of  Eirsch,  who  gives  us  the  particulars  of  21G  epidemics  occurring 
between  the  years  1652  and  1862. 

Bacon,  in  an  article  based  upon  the  records  of  the  health  department 
of  Chicago  for  the  forty  years  prior  to  1896,  shows  that  puerperal  infec- 
tion still  plays  a  very  prominent  part  in  the  death  list,  being  the  cause  of 
death  assigned  in  12.75  per  cent  of  the  women  dying  between  the  ages  of 
twenty  and  fifty  years.  In  1873,  20  per  cent  of  all  women  dying  in  Chicago 
between  these  ages  succumbed  to  puerperal  sepsis.  Happily,  the  mortality 
has  gradually  fallen,  reaching  6  per  cent  in  1892,  and  being  recorded  as 
7.3  per  cent  in  1895.  These  results  are  substantiated  by  those  of  Ingerslev, 
who  states  that,  even  at  the  present  time  in  Denmark,  with  the  single  ex- 
ception of  tuberculosis,  puerperal  infection  is  the  most  frequent  cause  of 
death  in  women  between  the  ages  of  twenty  and  fifty  years. 

The  investigations  of  Boxall  and  Byers  show  a  similar  condition  in  Eng- 
land, where  it  may  be  said  that  outside  of  the  lying-in  hospitals  this  pre- 
ventive scourge  claims  as  many  and  perhaps  more  victims  as  it  did  twenty 
or  even  forty  years  ago. 

Moreover,  in  trying  to  determine  the  frequency  of  puerperal  infection, 
one  cannot  be  guided  altogether  by  the  mortality  statistics,  inasmuch  as  the 
largest  proportion  of  these  cases  do  not  end  fatally.  On  the  other  hand, 
any  one  who  deals  mainly  with  gynaecological  work  cannot  fail  to  be 
impressed  with  the  very  large  proportion  of  patients  whose  troubles  have 
originated  from  febrile  affections  during  the  puerperium,  which  in  many 
cases  were  clearly  due  to  the  neglect  of  aseptic  precautions  on  the  part  of 
the  obstetrician  or  midwife. 

Symptoms. — As  was  stated  when  considering  the  pathological  anatomy 
of  puerperal  infection,  the  common  lesion  is  an  endometritis.  This  may  be 
either  of  the  septic  or  putrid  variety,  each  type  presenting  a  group  of 
more  or  less  characteristic  symptoms. 

In  the  cases  of  septic  endometritis,  after  everything  has  gone  smoothly 
for  the  first  three  or  four  days  of  the  puerperium,  the  patient  suddenly 
experiences  some  malaise,  and  may  complain  of  headache  and  a  feeling  of 
chilliness,  or  she  may  have  a  well-defined  chill,  the  temperature  soon  rising 
to  103°  F.  or  higher.  Generally,  only  one  rigor  occurs,  after  which  the 
temperature  remains  constantly  elevated.  At  the  same  time  there  is  some 
tenderness  in  the  lower  part  of  the  abdomen,  the  uterus  is  larger  and  more 
clo^KyTn  consistency  than  it  should  be,  and  is  sensitive  on  pressure.  The 
lochial  discharge  is  sometimes  increased  in  quantity,  and  is  partly  bloody, 
partly  purulent  in  character,  although  in  the  purely  septic  forms  it  is 


778  OBSTETRICS 

practically  devoid  of  odour.  If  the  temperature  is  very  high,  the  secretion 
is  not  infrequently  diminished  in  amount,  and  occasionally  disappears 
almost  entirely. 

The  character  of  the  uterine  discharges  in  these  cases  often  leads  to  a 
mistake  in  diagnosis,  for  the  average  practitioner  associates  puerperal  infec- 
tion with  profuse  and  foul-smelling  lochia;  whereas,  in  reality  in  the  most 
virulent  cases,  and  especially  in  those  due  to  a  pure  streptococcus  infec- 
tion, there  is  very  little,  if  any,  odour  to  he  noticed,  and  its  absence,  there- 
fore, is  not  necessarily  a  favourable  indication,  but  rather  the  reverse. 

Another  point  of  importance  is  the  faulty  involution  of  the  uterus. 
This  must  be  looked  upon  as  an  important  factor  in  the  further  spread  of 
the  disease,  for,  as  has  already  been  said,  the  micro-organisms  make  their 
way  through  the  muscular  walls  of  the  uterus  by  means  of  the  lymphatics, 
and  when  the  organ  is  markedly  relaxed  these  channels  are  more  patent 
and  offer  far  less  resistance  to  the  outward  passage  of  the  bacteria  than 
when  firm,  normal  contraction  is  present. 

The  further  history  of  septic  endometritis  varies  according  as  the  pro- 
cess remains  limited  to  the  cavity  of  the  uterus  or  extends  beyond  it.  In 
the  former  case  the  temperature  gradually  falls,  the  secretion  becomes  less 
and  less,  and  the  patient  is  slowly  restored  to  health.  In  the  majority  of 
cases,  however,  the  mucosa  is  not  restored  to  its  normal  condition  at 
once,  but  for  a  long  time  remains  the  seat  of  a  subacute  or  chronic  inflamma- 
tion. When  the  process  has  extended  beyond  the  uterus,  the  symptoms  will 
vary  according  to  the  organs  involved,  and  those  belonging  to  a  parametri- 
tis, peritonitis,  or  pyaemia,  as  the  case  may  be,  are  superadded. 

The  clinical  picture  presented  by  a  putrid  endometritis  differs  somewhat 
from  that  characterizing  the  septic  form.  Here  we  likewise  have  the  initial 
chill  and  the Jrigb.  temperature,  but  the  patient's  condition  does  not  usu- 
ally appear  so  serious.  The  main  difference,  however,  between  the  two 
varieties  is  to  be  noted  in  the  character  of  the  uterine  discharge,  which  in 
the  putrid  cases  is  abundant,  very  foul-smelling,  and  frequently  has  a  frothy 
appearance  on  account  of  the  large  number  of  gas  bubbles  contained  in  it. 
These  cases  usually  eventuate  in  recovery,  and  only  in  rare  instances  termi- 
nate fatally. 

Between  these  two  well-marked  classes  of  cases,  however,  there  exist 
all  gradations,  and  not  uncommonly  we  have  to  deal  with  a  mixed  infection 
due  to  pyogenic  as  well  as  putref active  organisms. 

As  has  already  been  said,  the  chill  and  rise  of  temperature  are  occasion- 
ally associated  with  localized  iilceratjrm  ahrmf.  the  vnlva.  or  somewhere  in  the 
vagina.  In  the  vast  majority  of  cases,  however,  the  puerperal  ulcer  or 
vaginitis  does  not  occur  alone,  but  is  accompanied  by  an  endometritis. 

The  extension  of  the  process  from  the  uterine  cavity  or  from  ulcers 
about  the  cervix  to  the  parametrium  produces  an  array  of  more  or  less 
characteristic  manifestations.  In  many  cases  the  initial  rise  of  tempera- 
ture lasts  only  for  a  short  time,  and  we  are  congratulating  ourselves  that 
our  patient  has  escaped  so  easily  when  suddenly  another  chill  occurs,  the 
fever  rises  again,  to  pursue  a  more  or  less  irregular  course,  usually  marked 
by  evening  exacerbations.  T  This  may  continue  for  some  time  without  any 


ITKHPKUAL    IXFKCTIoN  779 

local  manifestation;  but,  sooner  or  Later,  earefu]  abdominal  palpation  will 
reveal  the  presence  of  a  mass  on  one  or  both  fides  of  the  uterus,  due  to 
pus  formation  within  the  lolds  of  the  broad  ligament.  The  abscess  may 
be  limited  to  the  broad  Iigaim nt  itself,  or  may  extend  along  the  connective 
tissue  upon  the  anterior  portion  of  the  pelvis  up  to  the  neighbourhood  of 
Poupart's  ligament;  in  other  eases  again,  it  extends  backward  towards  the 
retroperitoneal  region.  The  fever  continues  until  the  abscess  ruptures  spon- 
taneously or  has  been  opened,  except  in  a  few  cases  in  which  it  undergoes 
gradual  resorption,  leaving  a  mass  of  cicatricial  tissue  to  mark  its  former 
situation.  If  not  operated  upon,  a  parametritic  abscess  may  burst  spontane- 
ously into  the  rectum  or  bladder,  and  occasionally  through  the  abdominal 
wall  in  the  region  of  the  inguinal  canal.  Unless  it  ruptures  into  the  perito- 
neal cavity  the  patient  usually  recovers. 

In  certain  instances  the  infection  extends  from  the  uterine  cavity  to 
the  Fallopian  tubes,  and  there  gives  rise  to  a  salpingitis  with  its  accom- 
panying symptoms.  A  large  proportion  of  the  eases  of  pyosalpinx,  which 
come  to  operation  months  or  years  later,  have  originated  in  this  manner, 
particularly  after  infection  following  abortions. 

Unfortunately,  it  sometimes  happens  that  the  process  does  not  remain 
limited  to  the  uterus  or  to  the  parametrium,  but  the  micro-organisms  make 
their  way  through  the  lymphatics  of  the  muscular  wall  of  the  uterus  to  the 
peritonamm,  and  there  excite  a  peritonitis;  though  in  exceptional  instances 
it  may  result  from  an  extension  of  the  inflammation  from  the  tubes,  and 
occasionally  from  the  rupture  of  a  parametritic  or  ovarian  abscess  or  of  a 
pyosalpinx. 

Somewhat  rarely  the  peritoneal  implication  is  limited  to  the  portion 
lining  the  pelvic  cavity — pelvic  peritonitis.  If  the  process  does  not  spread, 
the  chances  are  that  the  patient  will  recover,  but  if  the  peritonaeum  be 
invaded  to  any  great  extent  death  is  almost  inevitable.  The  character- 
istic symptoms  of  peritonitis  may  make  their  appearance  at  almost  any 
time  during  the  puerperium,  but  rarely  come  on  before  the  third  or  fourth 
day.  or  later  than  the  end  of  the  first  week,  unless  they  are  due  to  rupture 
of  an  abscess. 

When  the  patient  is  infected  with  very  virulent  streptococci,  the  endo- 
metritic  implication  is  usually  very  slight,  and  practically  the  first  sign  of 
infection  appears  from  the  side  of  the  peritonamm.  A  marked  rigor  occurs, 
the  temperature  rises  rapidly  and  remains  constantly  elevated^  the  pulse 
becomes  rapid,  and  later  on  very  weak  and  thready  in  character.  The 
patient  complains  of  intense  pain,  which  is  at  first  limited  to  the  lower 
portion  but  gradually  extends  over  the  entire  abdomen.  At  the  same  time 
there  is  marked  tympanites,  and  the  abdominal  walls  are  rendered  tense 
by  the  distended  intestines.  If  a  fatal  issue  ensues,  death  usually  occurs 
within  the  first  ten  da}*s  of  the  puerperium,  the  patient  gradually  sinking, 
although  she  may  remain  conscious  to  the  last.  In  rare  cases  the  tempera- 
ture is  but  little  elevated  and  the  pain  slight,  the  serious  character  of 
the  condition  being  indicated  only  by  the  rapid  and  compressible  pulse. 

In  the  cases  of  pi/cpmia,  on  the  other  hand,  the  clinical  picture  is  very  dif- 
ferent.   Here  the  initial  chill  does  not  occur  so  early,  and  the  temperature 


780  OBSTETRICS 

does  not  remain  constantly  elevated,  but  instead  we  have  a  typical  hectic 
fever,  with  the  chill,  high  temperature,  and  remission  recurring  in  succes- 
sion. The  symptoms  of  pyaemia  vary  very  considerably,  according  as  it  is 
the  result  of  the  dislodgment  of  a  single  thrombus  or  of  the  constant 
entry  into  the  blood  of  small  infected  particles.  In  the  first  instance  we 
have  a  metastasis  produced  at  some  one  point,  the  symptoms  depending 
upon  the  organ  involved.  On  the  other  hand,  if  thrombi  are  being  con- 
stantly dislodged  we  may  have  symptoms  referable  to  various  organs. 

One  of  the  most  constant  manifestations  of  pyaemia  is  an  infectious 
broncho-pneumonia,  which  contributes  to  the  fatal  termination.  In  other 
cases  swellings  occur  at  the  various  joints  which  frequently  eventuate  in 
suppuration  and  lead  to  total  destruction  of  the  tissues  implicated.  The 
course  of  pyaemia  varies  very  materially  according  to  the  organs  attacked 
and  the  resisting  powers  of  the  patient,  but  it  is  nothing  like  so  uniformly 
fatal  as  the  peritonitic  form  of  infection. 

In  a  certain  number  of  cases  the  infection  is  so  virulent  that  the  organ- 
isms do  not  have  a  chance  to  become  localized  in  any  one  organ,  and  both 
they  and  their  toxines  are  found  in  abundance  in  the  circulating  blood,  with 
very  slight  implication  of  the  uterus.  This  happens  in  cases  of  so-called 
S£gtjxcemia,  which  represents  the  most  rapidly  fatal  form  of  infection, 
the  patients  occasionally  dying  on  the  second  or  third  day  of  the  puer- 
perium  in  a  condition  of  shock,  and  without  the  development  of  local 
symptoms.  A  case  of  streptococcus  septicaemia,  observed  recently  in  our 
out-patient  department,  ended  fatally  within  eighteen  hours  after  the  initial 
rise  of  temjDerattire. 

In  a  small  number  of  cases  the  thrombotic  process  involving  the  pelvic 
veins  may  extend  to  the  femoral  vein  on  one  or  both  sides,  giving  rise  to 
jJilct/nitisia  alha  ijjjjrns.  This  accident,  as  a  rale,  does  not  make  its  appear- 
ance until  some  time  in  the  second  week  of  the  puerperium,  or  even  later,' 
the  first  symptom  being  pain  along  the  course  of  the  femoral  vessels,  which 
in  thin  individuals  may  be  felt  as  hard,  sensitive  cords.  At  the  same  time 
oedema  appears  in  the  feet  and  soon  extends  upward,  though  occasionally 
it  may  appear  first  in  the  thigh.  This  swelling  is  associated  with  severe 
pain,  and  usually  lasts  for  a  considerable  time,  months  sometimes  elapsing 
before  the  patient  can  walk  with  comfort.  At  the  same  time  the  condition 
is  rarely  fatal  unless  some  complication  occurs.  At  the  onset  of  certain 
cases  of  phlegmasia  the  patients  complain  of  severe  pain  about  the 
chest.  This  symptom  is  attributed  by  Pinard  and  Wallich  to  the  arrest 
of  small  thrombi  in  the  pleural  vessels  which  give  rise  to  isolated  areas 
of  pleurisy. 

In  a  certain  number  of  cases  infection  may  occur  before  the  birth  of 
'the  child.  This  is  designated  as  intra-partum  infection,  and  usually  occurs 
in  slow  labours  in  which  the  membranes  have  ruptured  at  an  early  period.. 
Under  such  circumstances  the  temperature  may  be  markedly  elevated  and 
the  patient  present  a  profoundly  septic  appearance  even  before  delivery. 
When  the  temperature  during  labour  rises  above  100.5°  F.,  we  should  always 
think  of  this  complication,  and  at  once  institute  procedures  to  hasten  the 
evacuation  of  the  uterus. 


PUERPERAL   INFECTION  781 

Diagnosis. — The  diagnosis  of  puerperal  fever  is  usually  made  without 
difficulty,  as  the  clinical  history  is  very  significant. 

II'  a  patienl  who  lias  been  doing  well  after  delivery  has  a  chill  and  a 
rise  of  temperature  on  the  third  or  fourth  day,  we  may  be  practically  sun; 
ilia!  we  have  to  deal  will)  an  infection,  unless  we  can  account  for  the  symp- 
toms by  sonic  other  satisfactory  cause.  In  many  cases  the  initial  chill 
does  not  occur,  and  the  lii'st  indication  of  the  condition  is  a  rise  of  tem- 
perature. In  general,  a  temperature  exceeding  100.4°  F.  (38°  ('.).  and  per- 
sisting for  more  than  twenty-four  hours,  should  be  regarded  as  an  a  priori 
evidence  of  infect  ion. 

In  the  old  times  it  was  believed  that  the  onset  of  the  lacteal  secretion 
was  accompanied  by  fever,  and  the  older  observers  were  always  ready  to 
attribute  a  rise  of  temperature  on  the  third  or  fourth  day  to  this  cause.  At 
the  present  time,  however,  this  so-called  "  milk  fever"  is  no  longer  regarded 
as  a  morbid  entity,  as  we  know  that  the  normal  puerperium  should  be  abso- 
lutely afebrile. 

After  the  infection  has  become  well  established,  either  as  an  endome- 
tritis, peritonitis,  or  one  of  the  other  forms,  the  diagnosis  is  generally  easy. 
In  uncomplicated  cases  of  puerperal  endometritis  usually  very  little  pain 
is  complained  of,  and  it  sometimes  becomes  a  difficult  matter  to  decide 
positively  whether  the  temperature  is  due  to  a  uterine  infection  or  some 
other  cause. 

In  a  certain  number  of  instances  a  febrile  movement  may  occur  on  the 
third  or  fourth  day  which  may  justifiably  be  ascribed  to  emotional  causes, 
such  as  excitement,  fright,  or  grief.  The  temperature  may  ris~e  suddenly, 
and  after  reaching  a  considerable  height  promptly  fall  to  normal  within  a 
few  hours.  At  first  we  should  always  suspect  a  beginning  infection,  and 
it  is  only  after  the  rapid  subsidence  of  the  symptoms  that  such  a  diagnosis 
is  permissible. 

Xow  and  again  a  post-partum  rise  of  temperature  is  caused  by  auto- 
intoxication from  the  intestijjjaljract.  Special  attention  has  been  devoted  to 
this  subject  by  Sudin  and  Galtier,  who  state  that  in  some  instances  such 
a  condition  may  closely  simulate  puerperal  infection.  The  diagnosis  is 
readily  arrived  at,  however,  by  the  administration  of  a  purgative,  for  after 
a  copious  movement  of  the  bowels  the  temperature  falls  rapidly  and  remains 
normal. 

Again,  fever  occurring  in  the  early  part  of  the  puerperium  is  not  un- 
commonly due  to  iirflamm|rixHW_J^  but  the  subse- 
quent history  of  the  case  readily  clears  up  the  question  of  diagnosis. 

In  addition  to  the  more  usual  causes  of  fever  during  the  puerperium  not 
due  to  infection,  many  intercurrent  diseases  may  be  accompanied  by  a  chill 
and  high  temperature  which  for  a  short  time  may  make  one  suspect  a  puer- 
peral infection,  although  the  subsequent  history  of  the  case  may  show  that 
one's  fears  have  been  groundless.  This  is  frequently  so  in  angina  and 
acute  pulmonary  affections  which  may  occur  at  any  time  during  the  puer- 
perium. 

Occasionally,  prolonged  suppurative  processes  in  the  pelvis  may  be  ac- 
companied by  symptoms  which  may  readily  be  confounded  with  one  or 


782  OBSTETRICS 

other  of  these  diseases,  but  in  the  present  state  of  our  knowledge  there  is 
no  reason  why  we  should  long  remain  in  doubt  as  to  the  cause  and  origin 
of  the  fever  in  a  given  case. 

There  are  two  diseases,  however — malaria  and  typhoid  fever — that  are 
frequently  confounded  with  puerperal  infection,  and  that  are  often  made 
the  scapegoat  to  shield  the  practitioner  who  has  neglected  aseptic  precau- 
tions in  the  conduct  of  his  case.  While  there  is  no  doubt  that  either  of 
these  affections  may  occur  during  the  puerperal  period,  in  the  vast  majority 
of  cases  the  diagnosis  is  open  to  question. 

If  the  symptoms  be  due  to  malaria,  one  should  be  able  to  demonstrate  the 
presence  of  the  specific  organisms;  and  in  default  of  a  positive  examina- 
tion of  the  blood  one  is  not  justified  in  regarding  an  elevated  temperature 
and  an  occasional  chill  occurring  during  the  puerperium  as  of  malarial 
origin.  Indeed,  it  would  be  far  better  to  go  still  further  and  make  it  a 
rule  that  one  is  never  justified  in  excluding  a  puerperal  infection  as  a 
probable  causative  factor  unless  cultural  methods  have  demonstrated  that 
the  uterine  cavity  is  free  from  all  pathogenic  organisms;  for  it  is  possible 
that  in  a  certain  number  of  cases  a  puerperal  infection  may  be  associated 
with  malarial  poisoning,  and  without  the  bacteriological  examination  of 
the  uterine  lochia,  after  finding  the  specific  plasmodia  in  the  blood,  one 
might  be  satisfied  of  the  exclusive  malarial  origin  of  the  symptoms,  where- 
as, in  reality  they  are  partially  due  to  infection.  Judged  by  these  criteria, 
a  malarial  fever  complicating  the  puerperium  will  appear  in  health  statistics 
far  less  frequently  than  at  present. 

At  the  same  time,  there  is  no  doubt  that  occasionally  a  latent  malarial 
infection  may  suddenly  burst  out  again  during  the  puerperium.  Thus,  in 
several  of  our  cases  the  women  had  chills  followed  by  fever,  and  we  were 
able  to  demonstrate  the  presence  of  quartan  malarial  organisms  in  the 
blood,  and  at  the  same  time  to  make  sure  of  the  absolute  sterility  of  the 
uterine  lochia. 

The  diagnosis  of  typhoid  fever  is  very  frequently  made  in  prolonged 
cases  of  puerperal  infection,  being  based  by  the  average  observer  on  the 
long-continued  fever  and  the  general  prostration  of  the  patient.  ]STo  doubt 
typhoid  fever  may  be  an  occasional  complication,  but  every  one,  who  will 
make  a  point  of  inquiring  fully  into  the  many  instances  of  which  he  hears, 
will  soon  be  convinced  that  only  a  small  proportion  of  the  cases  so  desig- 
nated are  really  typhoid  in  origin,  and  that  most  of  them  depend  upon  an 
infection  of  the  genital  tract.  In  the  present  state  of  our  knowledge,  espe- 
cially since  Widal's  discovery  of  the  agglutinative  action  of  the  blood  serum 
of  typhoid  patients  upon  cultures  of  typhoid  bacilli,  we  are  not  justified 
in  making  a  diagnosis  of  typhoid  fever  unless  this  specific  action  can  be 
demonstrated. 

On  the  other  hand,  typhoid  fever  complicating  the  puerperium  may 
simulate  very  closely  a  puerperal  infection,  and  Jung  has  recently  de- 
scribed several  cases  in  which  this  mistake  was  made,  the  true  nature  of  the 
malady  not  being  discovered  until  autopsy. 

To  sum  up,  it  may  be  safely  said  that  every  rise  of  temperature  ob- 
served in  a  puerperal  woman  should  be  regarded  as  due  to  infection  until 


PUERPERAL   INFECTION  ^'-'> 

it  has  been  clearly  demonstrated  thai  sonic  other  exciting  cause  is  respon- 
sible. Eence  it  follows  thai  in  making  a  diagnosis  of  any  affection  com- 
plicating the  puerperium,  an  accurate  and  complete  physical  examination 
of  the  patient  is  necessary,  and  at  the  same  time  all  the  aids  which  thi 
recent  advances  in  microscopy  and  bacteriology  have  placed  at  our  command 
should  be  utilized. 

Bacteriological  Examination  of  the  Lochia. — As  the  most  common  lesion 
in  puerperal  infection  is  an  endometritis,  it  is  a  matter  of  some  importance 
to  decide  whether  one  has  to  deal  with  the  septic  or  putrid  variety;  but 
although  in  many  cases  the  clinical  symptoms  will  give  tolerably  defi- 
nite indications,  a  positive  conclusion  can  be  arrived  at  only  after  a  bacte- 
riological examination  of  the  uterine  lochia,  putrefactive  organisms  being 
obtained  in  the  saprsemic  and  pyogenic  organisms,  more  especially  the 
streptococcus,  in  the  septic  types.  In  gonorrheal  infections  the  develop- 
ment of  a  purulent  ophthalmia  on  the  part  of  the  child  affords  an  almost 
positive  diagnosis,  but  even  in  such  cases  one  is  not  sure  that  other  organ- 
isms may  not  be  concerned. 

Cultures  may  be  taken  from  the  interior  of  the  uterus  with  compara- 
tively little  difficulty  by  means  of  a  simple  device  first  introduced  by  D6- 
derlein.  This  consists  of  a  glass  tube  20  to  25  centimetres  in  length  and  3 
to  4  millimetres  in  diameter,  with  a  slight  bend  at  one  end  so  as  to  conform 
to  the  antenexeel  condition  of  the  uterus.  For  practical  purposes  it  is  most 
conveniently  sterilized  by  dry  heat  in  a  long  tube  of  thick  glass  plugged 
with  cotton,  in  which  it  can  afterward  be  carried  about  ready  for  immediate 
use  without  fear  of  contamination.  In  an  emergency,  however,  it  may  be 
sterilized  by  boiling. 

When  cultures  are  to  be  made  from  the  uterus,  the  instruments  and 
hands  of  the  operator  and  the  external  genitalia  of  the  patient  having 
been  thoroughly  disinfected,  the  patient  is  placed  in  the  Sims's  or  dorsal 
position  and  the  posterior  vaginal  wall  retracted  by  a  suitable  speculum. 
The  cervix  is  then  seized  and  brought  into  view  with  a  volsellum  forceps, 
and,  its  vaginal  portion  having  been  carefully  cleansed  with  a  bit  of  steril- 
ized cotton,  the  lochial  tube  is  removed  from  its  container  and  introduced 
as  far  as  possible  into  the  uterus,  care  being  taken  to  avoid  touching  the 
external  genitalia  with  it  during  the  manipulation.  To  the  end  of  the 
lochial  tube  protruding  from  the  vulva  a  large  syringe  is  attached  by 
means  of  a  piece  of  rubber  tubing.  On  making  suction  a  certain  amount  of 
the  uterine  contents  is  drawn  up  into  the  tube,  which  is  then  removed  from 
the  uterus  and  its  ends  hermetically  closed  with  sealing-wax.  It  is  then 
replaced  in  its  container  and  taken  to  the  laboratory,  where  it  is  broken  in 
its  middle  portion  and  cultures  made  from  the  contents  (Fig.  630). 

This  method,  although  it  may  appear  to  be  somewhat  complicated,  can 
be  readily  carried  out  by  any  practitioner  who  is  conversant  with  the  ordi- 
nary rules  of  surgical  technique,  and  if  the  tube  be  sent  to  a  competent 
bacteriologist  for  examination  it  can  be  determined  within  twenty-four 
hours  whether  the  infection  is  due  to  pyogenic  or  putrefactive  bacteria, 
and  whether  one  has  to  deal  with  a  dangerous  or  a  comparatively  harmless 
condition. 


m 


OBSTETRICS 


^"-3M 


In  my  practice  such  a  procedure  forms  a  part  of  the  routine  exami- 
nation in  every  case  presenting  a  rise  of  temperature  above  101°  F. 
The  satisfaction  of  knowing  exactly  with  what  form  of  infection  we  have 
to  deal  amply  repays  for  the  trouble  taken,  and  at  the  same  time  the 
recognition  of  the  infective  agent  gives  important  indications  as  to 
treatment. 

After  removing  the  specimens  of  lochia  for  bacteriological  examina- 
tion, provided  the  cervix  is  sufficiently  patulous,  it  is  well  to  introduce 

the  sterile  finger  into  the  uterus  and 
feel  its  interior,  after  which  a  douche 
of  several  litres  of  normal  salt  solution 
should  be  given.  Palpation  of  the  cav- 
ity of  the  uterus  enables  us  in  many 
cases  to  predict  in  advance  the  result 
of  the  bacteriological  examination,  and, 
what  is  of  more  practical  value,  gives 
us  important  information  as  to  the  line 
of  treatment  to  be  pursued.  Thus,  in 
putrid  endometritis  and  infections  due 
to  the  colon  bacillus,  we  usually  find 
the  surface  of  the  uterine  cavity  rough 
and  covered  with  shreds  of  broken- 
down  tissue;  while  in  the  septic  forms 
its  interior  is  often  perfectly  smooth. 

The  macroscopic  appearance  of  the 
lochia  is  also  of  considerable  value,  for 
in  a  putrid  endometritis  the  discharge 
is  frothy  and  frequently  very  offensive 
in  odour,  while  in  pure  streptococcic 
infections  it  is  very  little  changed  from 
the  normal.  This  distinction  needs 
to  be  especially  emphasized,  since  the 
first  question  which  the  practitioner 
usually  asks  the  nurse  in  the  presence 
of  fever  during  the  puerperium,  is 
whether  the  lochia  are  foul-smelling 
or  not,  and  if  he  receives  a  negative 
answer  he  is  too  apt  to  think  that  the 
fever  is  of  other  than  uterine  origin. 
As  a  matter  of  fact,  the  reverse  is 
almost  constantly  true,  and,  as  a  rule,  the  foulness  of  the  odour  is  in 
inverse  proportion  to  the  danger  to  which  the  patient  is  exposed. 

When  the  process  has  extended  beyond  the  uterus  the  diagnosis  is 
much  more  readily  made,  and,  provided  that  malarial  or  typhoid  fever  and 
acute  miliary  tuberculosis  have  been  positively  excluded,  it  is  hardly  pos- 
sible  to  mistake  the*  symptoms  produced  by  a  peritonitis  or  by  a  pysemia. 
In  the  cases  of  parametritis  and  suppurative  affections  of  the  tubes  and  ova- 
ries, bimanual  examination  will  demonstrate  the  presence  of  a  mass,  on  one 


Fig.  630. — Doderlein's  Tube  for  removing 
Uterine  Lochia. 


PUERPERAL   INFECTION  785 

or  other  side  of.  the  uterus,  if  the  tumour  has  not  already  made  itself  evident 
to  abdominal  palpation. 

Prophylactic  Treatment. — In  considering  the  treatment  of  puerperal 
fever,  prophylaxis  should  occupy  the  most  important  place,  ka  has  been 
repeatedly  insisted,  puerperal  infection  is  wound-infection,  and  is  due  to 
the  introduction  of  pathogenic  micro-organisms  by  the  hands  or  instru- 
ments of  the  doctor  or  nurse.  Hence  it  naturally  follows  that  the  ihd'sl 
scrupulous  asepsis  immediately  before  and  during  labour  is  the  means  upon 
u  hich  we  have  mainly  to  rely  to  limit  its  occurrence.  Every  physician  who 
conducts  a  labour  case  cannot  feel  too  strongly  his  personal  responsibility  in 
this  connection,  and  he  fails  to  do  his  full  duty  to  his  patient  unless  lie 
regards  the  rules  of  asepsis  as  carefully  as  when  performing  a  capital  sur- 
gical operation.  This  question  with  all  its  various  phases  has  been  fully 
dealt  with  in  the  appropriate  chapters. 

All  that  has  been  said  concerning  the  necessity  of  cleanliness  and 
asepsis  on  the  part  of  the  physician  applies  equally  well  to  the  nurse,  and  in 
all  her  manipulations  about  the  patient  she  should  never  tbrgei;  her  respon- 
sibility in  this  respect.  Moreover,  she  should  he  strictly  forbidden  to  make 
vaginal  examinations  or  give  douches  except  at  the  direct  request  of  the 
physician  in  charge. 

As  long  as  vaginal  examinations  are  made,  no  matter  how  carefully 
we  may  attempt  to  sterilize  our  hands,  infection  will  occasionally  occur. 
For  this  reason  vaginal  examinations  should  be  dispensed  with  as  far  as 
possible,  and  with  this  end  in  view  the  accoucheur  should  never  lose 
an  opportunity  of  perfecting  himself  in  the  methods  of  external  exami- 
nation. 

In  view  of  what  has  already  been  said  concerning  the  bacterial  con- 
tents of  the  vagina,  and  the  results  of  the  experiments  of  Leopold  and 
others,  which  have  been  confirmed  by  my  own  personal  experience,  I 
strongly  advise  against  the  employment  of  the  prophylactic  douche  as  a  rou- 
tine procedure,  believing  that  it  should  be  resorted  to  only  when  the  vaginal 
secretion  presents  marked  evidences  of  abnormality. 

During  the  second  stage  of  labour  it  is  well  to  have  the  vulva  cov- 
ered with  an  aseptic  pad  in  the  form  of  a  towel  soaked  in  bichloride  solu- 
tion. This  is  done  not  so  much  for  fear  of  infection  from  the  air,  as  to 
prevent  the  possibility  of  contamination  from  the  patient's  hands. 

The  third  stage  of  labour  likewise  offers  many  facilities  for  infection, 
and  too  much  stress  cannot  be  laid  upon  its  proper  conduct.  Speaking 
broadly,  the  generative  tract  after  the  birth  of  the  child  should  be  regarded 
as  a  noli  me  tangere,  unless  an  emergency,  such  as  a  haemorrhage  or  an 
adherent  placenta,  necessitates  the  introduction  of  the  hand. 

The  recommendation  tbat  a  routine  vaginal  examination  is  called  for  at 
the  conclusion  of  the  third  stage  of  labour  in  order  to  detect  cervical  tears 
with  a  view  to  their  immediate  repair,  cannot  be  too  strongly  deprecated, 
and  those  who  follow  it  will  inevitably  encounter  a  much  larger  percentage 
of  abnormal  puerperia  than  when  vaginal  examinations  at  the  conclusion  of 
the  third  stage  of  labour  are  reserved  for  exceptional  and  urgent  cases. 

Another  point  in  the  prophylaxis  of  puerperal  infection  is  to  close  with 
51 


786  OBSTETRICS 

sutures  immediately  after  the  conclusion  of  labour  any  perineal  wound  that 
extends  beyond  the  mucosa,  unless  the  procedure  is  contra-indicated  by  pro- 
found exhaustion  on  the  part  of  the  patient,  or  by  a  very  cedematous  condi- 
tion of  the  tissues  implicated.  To  save  time,  it  is  the  writer's  practice  to 
introduce  the  sutures  immediately  after  the  birth  of  the  child,  and  while 
waiting  for  the  expulsion  of  the  placenta. 

To  recapitulate,  the  liability  to  puerperal  infection  will  be  materially 
lessened  by  the  strict  observance  of  the  following:  (1)  The  maintenance 
of  asepsis  by  the  obstetrician  and  nurse  before,  during,  and  after  delivery; 
(2)  the  restriction  of  vaginal  examinations  within  the  narrowest  limits  pos- 
sible; (3)  the  omission  of  vaginal  douches  except  in  certain  rare  cases; 
(4)  the  immediate  repair  of  perineal  lacerations  which  might  otherwise  offer 
foci  for  infection;  and  (5)  regarding  the  genital  canal  of  the  puerperal 
woman  as  a  noli  me  tang  ere,  into  which  neither  finger  nor  instrument  should 
be  introduced  except  in  emergencies. 

Curative  Treatment.-^-Th.e  curative  treatment  of  puerperal  infection  is 
a  question  concerning  which  there  is  a  great  deal  of  dispute,  and  it  is  prob- 
able that  what  is  said  here  may  be  directly  opposed  to  the  usual  practice  of 
many  physicians. 

If  a  puerperal  ulcer  is  situated  about  the  vulva  or  on  the  lower  por- 
tion of  the  vagina,  it  should  be  occasionally  touched  with  pure  carbolic 
acid  or  tincture  of  iodine,  and  the  parts  kept  as  clean  as  possible.  If  the 
repaired  perinseum  breaks  down  and  suppurates,  the  stitches  should  be  re- 
moved in  order  that  free  drainage  may  be  provided. 

As  has  been  said,  puerperal  endometritis  is  the  form  of  infection  most 
frequently  encountered,  and  unfortunately  the  directions  for  its  treatment 
differ  widely  and  are  often  contradictory. 

As  soon  as  the  patient's  temperature  reaches  102°  F.,  unless  a  uterine 
infection  can  be  excluded  with  a  fair  amount  of  certainty,  the  uterine  lochia 
should  be  obtained  in  the  manner  described  above,  and  submitted  to  a 
bacteriological  examination.  When  feasible,  immediately  after  having  with- 
drawn the  tube,  the  sterilized  index  finger  should  be  introduced  and  the 
interior  of  the  uterus  carefully  explored,  after  which,  by  means  of  careful 
bimanual  examination,  the  condition  of  the  appendages  and  the  broad  liga- 
ments is  determined.  If^the  uterine  cavity  is  perfectly  smooth,  a  douche  of 
several  litres  of  boiled  water  or  normal  salt  solution  shoijld  be  given,  but 
curettage  should  not  be  thought  of.  On  the  other  hand,  if  its  interior  is 
rcmgh^and  jagged  and  contains  more  or  less  debris,  it  should  be  thoroughly 
cleaned  out  with  the  finger,  after  which  an  abundant  saline  douche  should 
be  employed. 

Curettage  as  a  routine  measure  in  all  cases  of  puerperal  endometritis 
is  by  no  means  to  be  recommended,  for  the  reason  that  in  the  most  severe 
cases  there  usually  is  absolutely  nothing  in  the  uterine  cavity  which  can  be 
removed,  and  its  employment  can  only  do  harm  by  breaking  down  the  leu- 
cocytic  wall  which  serves  to  prevent  the  invasion  of  the  deeper  layers  of 
the  uterus  by  the  offending  bacteria.  On  the  other  hand,  when  the  uterus 
contains  much  debris,  its  removal  is  more  readily  effected  by  means  of  the 
finger  than  by  the  curette. 


ITKUI'KRAL    INFECTION  787 

This  teaching  is  directly  contrary  to  thai  of  many  American  and  the 

majority  of  French  writers,  who  enthusiastically  rec mend  the  use  of  the 

curette  in  all  cases  of  puerperal  infection.  On  the  other  hand.  EPritsch, 
whose  views  represent   the  conservative  (lerman  doctrines  on  the  subject, 

would  reserve  its  use  for  exceptional  eases,  and  certainly  the  writer's  expe- 
rience has  convinced  him  of  the  advisability  of  this  restriction. 

'The  routine  use  n\'  bichloride  or  carbolic  intra-uterine  douches  in  the 
treatment  of  these  cases  is  contra-indicated  on  several  grounds.  In  cases 
due  to  virulent  streptococci,  a  histological  examination  shows  that  the 
organisms  have  penetrated  deep  down  into  the  tissues  by  the  time  the 
initial  chill  and  rise  of  temperature  occurs.  Under  these  circumstances 
the  employment  of  an  antiseptic  douche  is  not  rational,  inasmuch  as  the 
germicidal  fluid  cannot  possibly  penetrate  the  uterine  wall  sufficiently  deep 
to  reach  the  bacteria,  which  are  giving  rise  to  the  symptoms  and  upon  which 
the  further  spread  of  the  disease  is  dependent. 

Moreover,  it  has  been  shown  experimentally  by  Bumm  that  bichloride 
injections  penetrate  the  tissues  only  to  a  very  slight  extent.  He  took  the 
liver  of  an  animal  dead  of  anthrax,  and  after  soaking  it  for  thirty  minutes 
in  a  l-to-1,000  bichloride  solution  placed  it  upon  a  freezing  microtome  and 
cut  thick  sections  from  it.  After  cutting  off  about  tl  of  a  millimetre,  he 
inoculated  the  next  section  into  another  animal,  which  succumbed  to 
anthrax,  thus  showing  that  the  germicidal  action  of  the  bichloride  had  been 
exerted  only  upon  the  surface.  If  this  be  the  case  in  the  laboratory  after 
the  tissues  have  been  immersed  in  the  antiseptic  solution,  what  effect  can  we 
expect  upon  organisms  embedded  in  the  muscular  wall  of  the  uterus  from 
the  transitory  application  to  the  surface  of  a  few  litres  of  a  weak  bichloride 
solution?  Bumm  likewise  showed  that  the  streptococci  made  their  way 
through  the  uterus  with  great  rapidity,  travelling  2  centimetres  or  more  in 
the  space  of  six  hours.  What  has  been  said  concerning  bichloride  applies 
equally  well  to  the  other  disinfectants. 

On  the  other  hand,  their  employment  in  cases  of  putrid  endometritis  is 
even  less  rational.  In  the  vast  majority  of  such  cases  simply  cleaning  out 
the  uterus  with  the  finger  or  curette,  followed  by  a  douche  of  sterile  salt 
solution,  will  lead  to  a  rapid  fall  of  temperature  and  the  amelioration  of  un- 
toward symptoms.  The  object  in  giving  a  douche  in  these  cases  is  simply  to 
wash  away  the  debris  which  has  been  left  behind  by  the  finger,  and  for  this 
purpose  sterile  water  or  salt  solution  is  far  better  than  any  antiseptic  fluid. 

In  addition  to  these  somewhat  theoretical  objections,  there  is  this  very 
practical  one:  that  the  employment  of  antiseptics  may  do  an  immense 
amount  of  harm.  Xot  a  few  cases  of  sudden  collapse  following  the  use  of 
carbolic-acid  douches  are  on  record,  while  in  some  instances  intra-uterine 
injections  of  bichloride  have  been  proved  to  have  been  the  direct  cause  of 
death.  Several  years  ago,  at  the  autopsy  upon  a  woman  who  was  supposed  to 
have  died  from  puerperal  sepsis,  I  found  all  the  anatomical  lesions  of 
bichloride  poisoning,  so  that,  to  say  the  least,  it  remained  doubtful  whether 
the  infection  or  the  treatment  instituted  for  its  relief  was  responsible  for  the 
fatal  issue. 

On  reference  to  the  literature  at  that  time,  I  collected  some  46  cases 


788  OBSTETEJQS 

in  which  death  had  followed  the  employment  of  bichloride  douches  during 
the  puerperium.  In  many  instances,,  to  he  sure,  excessive  quantities  had 
been  employed,  but  in  several  a  single  injection  of  several  litres  of  a  1-to- 
4,000  solution  had  resulted  in  fatal  mercurial  poisoning.  When  these  facts 
are  taken  into  consideration,  along  with  the  theoretical  objectious  to  the 
employment  of  antiseptics  under  these  circumstances,  it  would  appear  that 
the  benefit  to  be  expected  from  their  employment  is  at  least  very  problemat- 
ical, while  the  dangers  are  very  real. 

The  results  following  the  method  of  tteatment  just  outlined  are  squite 
as  good  as  those  obtained  with  the  various  antiseptic  douches,  and  this 
contention  is  sustained  by  the  experience  of  Bumm  and  Kronig.  By  this 
means  I  have  treated  52  cases  of  streptococcic  endometritis,  with  2  deaths 
attributable  to  the  disease — a  mortality  of  less  than  4  per  cent.  In  30 
cases  I  had  to  deal  with  a  pure  streptococcic  Infection,  and,  all,  of  the  pa- 
tients recovered;  while  of  12  cases  in  which  it  was  associated  with  the 
colon  bacillus  or  other  organisms,  2  proved  fatal.  The  latter  figures  appar- 
ently bear  out  the  conclusions  of  Bar  and  Tissier,  that_comhined  infections 
with  Streptococcus  pyogenes  and  Bacillus  coli  are  much  more  dangerous 
than  infections  clue  to  either  organism  alone.  At  the  same  time  it  is  ;not 
desired  to  give  the  impression  that  pure  streptococcic  infections  are ,  devoid 
of  danger,  as  they  are  always  serious  and  often  fatal,  and  the  writer  ,f eels 
sure  that  he  must  inevitably  have  deaths  to  report  sooner  or  later.  Never- 
theless, ,,the. results  in  the  cases  just  mentioned  would  appear  to  indicate  that 
too  energetic  treatment  may  be  harmful,  and  that  an  equally  good  or  better 
outcome  can  be  obtained  by  safer  and  more  conservative  measures. 

To  recapitulate,  in  dealing  with  a  case  of  puerperal  endometritis  after 
having  removed  some  of  the  uterine  lochia  for  cultures,  the  cavity  should 
be  explored  by  the  sterile  finger  and  cleaned  out  or  not  according  to, its 
condition.  The  uterus  should  then  be  douched  with  several  litres  of  boiled 
water  or  sterile  salt  solution.  If  the  bacteriological  examination  shows 
tlie  presence  of  streptococci,  all  local  treatment  should  at  once  be. omitted. 
If,  on  the  other  hand,  one  has  to  deal  with  a  putrid  endometritis,  and  the 
symptoms  do  not  yield  to  the  first  injection,  additional  douches  may : be 
given.  When  the  infection  has  extended  beyond  the  uterus,  local  treatment 
should  not  be  persisted  in,  as  it  will  do  more  harm  than  good. 

Bumm  observed  that  in  many  instances  involution  had  taken  place  very 
incompletely,  and  he  therefore  recommended  the  employment  of  ergot  to 
secure  better  contraction,  thereby  occluding  to  a  greater  degree  the  lym- 
phatics in  the  uterine  wall.  My  own  experience  is  in  accord  with  this 
view,  and  in  cases  in  which  the  uterus  is  larger  than  it  should  be  at  a  given 
period  of  the  puerperium  the  employment  of  the  drug  would  certainly 
appear  to  be  indicated. 

In  gonorrhceal  endometritis  active  treatment  is  not  required  at  the  time, 
since  in  the  vast  majority  of  cases  the  slight  rise  of  temperature  associated 
with  the  onset  of  the  disease  soon  falls  to  normal,  and  the  patients  recover 
spontaneously  or  are  left  with  a  chronic  endometritis  and  diseases  of  the 
appendages,  which  can  be  treated  much  more  advantageously  at  a  later 
period. 


PUERPERAL   INFECTION  789 

In  all  severe  cases,  genera]  tonic  measures  thai  will  serve  to  keep  up  the 
strength  oi  fehe  patienl  and  increase  her  resistance  to  Hie  infective  virus 
are  most  valuable.  The  mosl  reliable  drugs  are  strychnine  and  alcohol, 
and  it  is  a  matter  of  experience  that  these  patients  can  bear  much  larger 
quantities  of  the  latter  than  when  in  health.  High  fever  should  not 
he  combated  with  antipyretics,  the  external  application  of  cold,  either 
in  the  form  of  spongings  or  cold  baths,  being  far  preferable.  Hydro- 
therapeutic  measures  have  been  enthusiastically  advocated  by  Mace, 
Win  me,  and  Dcst  ernes,  and  in  their  hands  have  given  very  satisfactory 
results. 

If  the  process  has  extended  beyond  the  uterus,  and  we  have  to  deal  with 
a  parametritis  or  a  pelvic  peritonitis,  dry  or  moist  heat  to  the  lower  por- 
tion of  the  abdomen  in  the  form  of  poiiltices  or~otlier  iiof  applications,  is  to 
be  recommended. 

Occasionally,  surprisingly  good  results  are  obtained  in  profoundly  septic 
conditions  by  repeated  subcutaneous  injections  of  sterile  salt  solution,.  At- 
tention was  first  directed  to  this  method  of  treatment  liyBosc,  and  subse- 
quent  experience  has  in  great  part  justified  his  predictions. 

Of  late  a  great  deal  has  been  written  on  the  operative  treatment  of 
puerperal  infection,  nearly  every  prominent  obstetrician  and  gynaecologist 
having  made  some  contribution  to  the  subject.  Every  one  is  agreed  as  to 
the  advisability  of  opening  ^parametritic  abscessesras  soon  as  fluctuation 
appears  rather  than  allowing  them  to  rupture  spontaneously.  Xot  un- 
commonly, in  cases  of  parametritis,  on  palpation  a  semi-fluctuant  sensa- 
tion is  conveyed  to  the  examining  finger  which  may  lead  one  to  suppose  that 
one  has  to  deal  with  pus,  whereas  upon  opening  the  supposed  abscess  through 
the  vagina  or  abdominal  wall,  as  the  case  may  be,  the  tumour  turns  out  to  be 
a  mass  of  inflammatory  exudate  without  pus  formation,  and  only  a  small 
amount  of  serous  fluid  will  escape  when  it  is  cut  into.  Fortunately,  incision 
into  these  masses  frequently  gives  as  good  results  as  if  a  considerable  quan- 
tity of  pus  had  been  evacuated,  just  as  happens  in  ordinary  cases  of  cellu- 
litis in  other  portions  of  the  body. 

When  pus  tubes  or  orarjari  a.hacessps  ran  be  made  out  by  bimanual  pal- 
pation, their  removal  isjargently  indicated,  for  as  long  as  they  remain  the 
patient  will  continue  in  a  septic  condition.  Whether  these  should  be  dealt 
with  by  laparotomy  or  by  puncture  through  the  vagina  will  depend  upon 
the  particular  case.  If  they  are  freely  movable,  laparotomy  should  be 
performed;  whereas  if  they  are  adherent  and  readily  accessible  from  below, 
vaginal  puncture  with  subsequent  packing  of  the  abscess  cavity  with 
gauze  is  to  be  preferred. 

The  chief  point  of  discussion  concerning  the  operative  treatment  of 
puerperal  infection  has  been  as  to  the  advisability  of  removing  the  infect- 
ed uterus  at  an  early  period.  Here  the  various  surgeons  take  quite  oppo- 
site views,  the  more  radical  advocating  its  prompt  removal,  while  the  more 
conservative  do  not  regard  this  step  with  favour. 

For  two  reasons  it  would  appear  that  hysterectomy  is  usually  contra- 
indicated  in  puerperal  infection.  In  the  first  place,  if  one  operates  at  a 
period  sufficiently  early  to  prevent  the  extension  of  the  process  to  other 


790  OBSTETRICS 

organs,  a  large  number  of  uteri  will  undoubtedly  be  removed  unnecessarily; 
on  tbe  other  hand,  if  one  waits  until  a  later  period,  when  other  organs  have 
become  implicated,  the  operation  will  also  be  useless.  Nevertheless,  there 
is  a  restricted  field  for  hysterectomy  in  those  cases  in  which  the  process 
has  not  extended  materially  beyond  the  uterus  but  has  given  rise  to 
abscess  formation  within  its  walls.  Again,  in  a  putrid  endometritis,  when 
all  other  attempts  to  check  the  disease  have  proved  futile,  the  operation 
would  appear  to  be  justifiable.  Sippel  has  reported  a  case  of  this  nature 
in  which  after  total  failure  of  all  other  methods  of  treatment  hysterectomy 
was  followed  by  complete  recovery. 

Lusk  suggested  that  hysterectomy  may  sometimes  be  useful  in  the  cases 
of  pyaemia  in  which  infected  thrombi  are  carried  from  the  uterus  to  various 
portions  of  the  body,  giving  rise  to  a  hectic  condition.  He  declares  that 
if  the  operation  be  clone  early  enough — say  after  the  second  rise  of  tem- 
perature— it  offers  a  very  reasonable  chance  of  success.  No  doubt  in  ex- 
ceptional cases  this  may  be  true,  but  as  a  rule  the  thrombosis  has  extended 
far  beyond  the  uterus  by  the  time  the  pyaemic  symptoms  make  their  appear- 
ance, and  the  operation  would  have  to  be  done  through  septic  tissue.  On 
the  whole,  the  question  of  hysterectomy  in  this  affection  would  seem  to  de- 
]3end  upon  our  ability  to  make  a  correct  diagnosis  and  to  foretell  the 
course  of  the  disease.  This,  however,  is  a  most  difficult  matter,  and  until 
more  accurate  means  of  diagnosis  and  prognosis  are  at  our  disposal  we 
do  not  believe  that  the  operation  will  be  very  generally  accepted.  This 
question  has  been  carefully  considered  by  Bumm  (1902),  who  arrived  at 
practically  the  same  conclusions. 

The  prospects  of  coping  more  successfully  with  puerperal  infection 
were  greatly  brightened  in  1895  by  Marmorek's  announcement  of  the  dis- 
covery of  an  antistreptococcic  serum.  Unfortunately,  up  to  the  present 
time  the  results  of  serum  therapy  have  not  proved  more  satisfactory  than 
other  methods  of  treatment.  In  May,  1899,  a  committee  of  the  American 
Gynaecological  Society,  of  which,  the  writer  was  chairman,  made  an  exhaust- 
ive report  upon  this  subject,  giving  the  complete  literature  and  collecting 
all  the  cases  treated  by  serum  reported  up  to  that  time.  They  found  that 
352  cases  of  puerperal  infection  had  been  so  treated,  with  73  deaths — a 
mortality  of  20.74  per  cent.  In  a  large  number  of  cases  the  lochia  were 
not  examined  bacteriologically,  and  there  was  therefore  considerable  doubt 
as  to  whether  the  infections  were  due  to  the  streptococcus;  but  in  101 
cases  in  which  its  presence  was  demonstrated  there  were  33  deaths — a  mor- 
tality of  32.69  per  cent. 

This  is  a  very  discouraging  showing,  especially  when  compared  to  the 
results  obtained  by  Kronig  and  the  writer  without  serum  therapy,  the 
former  having  treated  56  and  the  latter  52  cases  of  streptococcus  endome- 
tritis, with  a  mortality  of  less  than  4  per  cent.  The  question  therefore 
arises,  "Was  the  high  mortality  attending  the  use  of  the  antistreptococcic 
serum  due  to  its  employment  or  to  other  causes?  Our  investigations  hav- 
ing indicated  that  the  serum  was  practically  harmless,  the  poor  results  fol- 
lowing its  use  can  probably  be  explained  in  one  of  two  ways:  first,  that 
only  exceptionally  severe  cases  were  treated  by  it;  and  secondly,  that  a 


PUERPERAL    INFECTION  791 

Large  number  of  the  cases  so  i  reated  had  already  been  curetted — a  procedure 
which  is  often  followed  by  untoward  results. 

In  \  icu  of  these  facts,  the  committee  reported  that  there  was  no  evi- 
dence in  favour  of  the  1  herapeut  ic  value  of  antistreptococcic  serum,  although 
it  apparently  did  not  exert  a  deleterious  effect  upon  the  patient,  and  there- 
fore might  be  employed  if  the  physician  so  desired. 

Although  at  first  sight  it  would  seem  difficult  to  reconcile  these  con- 
clusions with  the  enthusiastic  reports  of  many  observers,  it  is  probable 
that  the  good  results  of  individual  practitioners  must  be  attributed  to 
the  fact  that  they  employed  the  serum  only  in  a  few  cases,  and  seem 
to  have  forgotten  that  most  cases  undergo  spontaneous  cure  if  not  inter- 
fered with. 

It  is  always  difficult  to  arrive  at  correct  conclusions  as  to  the  value  of 
any  given  therapeutic  agent,  unless  large  numbers  of  cases  are  used  as  a 
basis,  and  this  is  particularly  true  in  the  affection  under  consideration,  for 
the  reason  that  its  clinical  course  is  so  very  variable.  Thus,  it  is  not  at  all 
rare  in  cases  of  streptococcic  infection  to  see  the  temperature  rise  rapidly 
to  103°-105°  F.,  remain  there  for  a  day  or  so,  and  then  fall  as  rapidly  as 
it  had  risen.  This  may  occur  without  the  employment  of  any  treatment, 
and  had  the  specific  serum  been  employed  in  such  cases  it  is  more  than 
probable  that  the  rapid  amelioration  of  symptoms  would  have  been  attrib- 
uted to  its  use. 

That  we  as  yet  possess  no  satisfactory  treatment  for  all  cases  of  puer- 
peral infection  is  indicated  by  the  vast  number  of  methods  advocated  from 
time  to  time.  In  this  place  only  a  few  of  the  more  recent  need  be  men- 
tioned. 

Fochier  advocates  in  pyamiic  cases  the  production  of  what  he  calls 
absces  de  fixation — that  is,  the  production  of  abscesses  on  various  por- 
tions of  the  body  by  the  subcutaneous  injection  of  turpentine.  Fie  thought 
he  observed  that  the  condition  of  the  patient  improved  as  soon  as  the 
abscesses  made  their  appearance  on  the  surface,  and  his  method  of  treat- 
ment Avas  intended  to  simulate  Xature's  process.  Unfortunately,  experi- 
ence has  failed  to  strengthen  this  view. 

Kezmarsky,  in  1804,  reported  2  cases  of  severe  venous  sepsis  in  which 
he  gave  intravenous  injections  of  1  to  5  milligrammes  of  corrosive  subli- 
mate. He  noted  a  marked  effect  following  its  exhibition,  and  both  patients 
recovered.  His  work  was  enthusiastically  taken  up  by  Rissmann,  who 
likewise  reported  several  cures.  In  the  hands  of  others,  however,  the 
method  has  not  proved  satisfactory. 

Hofbauer,  in  1896,  reported  7  cases  of  puerperal  sepsis  in  which  he 
produced  an  artificial  leukocytosis  by  the  employment  of  nuclein.  In  some 
of  his  cases  the  temperature  fell  by  a  lysis  and  in  others  by  crisis,  and  he 
believed  that  the  artificial  leucoevtosis  played  a  marked  part  in  their  cure. 
Thus  far  no  one  has  substantiated  Hofbauer's  results,  but  Hirst  states  his 
belief  that  more  is  to  be  expected  from  this  line  of  treatment  than  from 
serum  therapy. 


792  OBSTETRICS 


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796  OBSTETRICS 

William's,  J.  W.     Puerperal  Infection  considered  from  a  Bacteriological  Point  of  View, 
with   Special   Reference    to    the   Question   of   Auto-Infection.     Amer.   Jour.   Med. 
Sciences,  July,  1893. 
The  Cause  of  the  Conflicting  Statements  concerning  the  Bacterial  Contents  of  the 
Vaginal  Secretion  of  the  Pregnant  Woman.    Amer.  Jour.  Obst.,  1898,  xxxviii,  807- 
817. 
The  Bacteria  of  the  Vagina  and  their  Practical  Significance,  based  upon  the  Bacterio- 
logical  Examination  of   the   Vaginal   Secretion   in   Ninety-two   Pregnant  Women. 
Amer.  Jour.  Obst.,  1898,  xxxviii,  449-483. 
Diphtheria  of  the  Vulva.     Amer.  Jour.  Obst.,  1898,  xxxviii,  180-185. 
Ein  Pall  von  puerperaler  Infektion,  bei  dem  sich  Typhusbacillen    in    den  Lochien 

fanden.     Centralbl.  f.  Gym,  1898,  Nr.  34. 
Puerperal  Diphtheria.     Amer.  Jour.  Obst.,  August,  1898. 
Williams,  Pryor,  Fry,  and  Reynolds.     The  Value  of  Antistreptococcic  Serum  in  the 

Treatment  of  Puerperal  Infection.     Trans.  Amer.  Gyn.  Soc,  1899,  xxiv,  80-126. 
Winter.     Die  Mikroorganismen  im  Genitalkanal  der  gesunden  Frauen.     Zeitschr.  f.  Geb. 

u.  Gyn.,  1888,  xiv,  443. 
Witte.     Bakteriologische  Untersuchungsbefunde  bei  path.  Zustanden  im  weibl.  Genital- 
apparat,  mit  besonderer  Beriicksichtigung  der  Eitererreger.     Zeitschr.  f.  Geb.  u. 
Gyn.,  1892,  xxv,  1-30. 
Wood.     Puerperal  Infection  caused  by  the  Bacillus  Aerogenes  Capsulatus.     Med.  Rec, 
April  15,  1899.     Ref.  Centralbl.  f.  Gyn.,  1900,  436,  Nr.  16. 


chaptp:e  xlv 

DISEASES  AND   ABNORMALITIES   OF   THE  PUERFEUICM 

We  have  already  discussed  in  detail  the  more  typical  instances  of  puer- 
peral infection.  We  shall  now  take  up  certain  atypical  varieties — tetanus, 
phlegmasia  alba  dolens,  and  cystitis — and  shall  then  proceed  to  ppnsider 
certain  other  diseases  and  abnormalities  which  may  be  encountered  in  the 
puerperium,  but  which  are  not  due  to  the  introduction  of  infective  material 
into  the  genital  tract.  Thus,  we  shall  find  that  fever  associated  with  con- 
stitutional disturbances  is  not  infrequently  met  with  as  the  result  of  patho- 
logical conditions  in  the  breasts,  disorders  of  the  intestinal  tract,  and  in 
v<Tv  rare  instances  of  emotional  causes.  Moreover,  it  must  be  remembered 
that  Xature  has  not  rendered  the  puerperal  woman  exempt  from  the  vari- 
ous disorders  from  which  she  might  suffer  at  other  times. 

Tetanus. — The  undoubted  development  of  tetanus  during  the  puerpe- 
rium, although  a  very  rare  occurrence,  has  been  fully  established  by  the 
researches  of  Chantemesse  and  Widal,  Heyse,  Eubeska,  and  others,  who 
have  isolated  the  characteristic  bacilli  from  the  uterine  lochia.  The  infec- 
tion usually  follows  gross  errors  in  antiseptic  technique,  especially  during 
operative  procedures.  Thus,  in  several  of  the  reported  cases,  it  is  recorded 
that  the  operator  placed  the  forceps  upon  the  dirty  floor  by  the  si<l<_*  of  the 
bed,  and  afterward  carried  it  directly  to  the  genital  tract  of  the  patient. 
Occasionally,  however,  such  an  explanation  cannot  be  adduced,  as  in  the 
recent  epidemic  in  the  Prague  Lving-in  Hospital,  the  disease,  in  one 
instance,  at  least,  occurred  in  a  woman  who  had  not  even  been  examined 
internally. 

The  disease  follows  abortion  more  frequently  than  full-term  labour, 
and  as  a  rule  gives  rise  to  untoward  manifestations  between  the  sixth  and 
tenth  days  of  the  puerperium,  and  sometimes  later,  though  in  rare  instances 
the  first  symptom  has  been  known  to  appear  before  the  completion  of 
labour.  The  prognosis  is  very  grave.  All  of  the  20  patients  mentioned  by 
Eubeska  succumbed,  while  Vinay  reports  a  similar  result  in  9i  out  of  the 
106  cases  included  in  his  statistics. 

Beyond  affording  means  for  temporarily  controlling  the  svmptoms, 
therapeutic  measures  are  valueless,  and  thus  far  the  results  obtained  from 
the  employment  of  anti-tetanus  serum  have  not  been  encouraging,  although 
its  prophylactic  employment  has  been  attended  by  excellent  results.  In 
view  of  the  hopelessness  of  other  lines  of  treatment,  Pawlik  and  Eubeska 
removed  the  uterus  in  several  of  their  cases,  but  without  avail. 

797 


798  OBSTETRICS 

Thrombosis  of  the  Vessels  of  the  Lower  Extremities. — Thrombosis  oc- 
curring in  the  crural,  popliteal,  or  saphenous  veins — phlegmasia  alba  dolens 
— is  usually  a  manifestation  of  infection,  and  follows  the  direct  extension  of 
a  thrombotic  process  from  the  pelvic  veins,  although  occasionally  it  results 
from  a  localized  phlebitis  or  periphlebitis.  The  lumina  of  the  large  veins 
rarely  undergo  complete  obliteration,  so  that  the  circulation,  while  mark- 
edly interfered  with,  is  not  completely  shut  off. 

Symptoms  of  phlegmasia  do  not  usually  make  their  appearance  until 
the  latter  part  of  the  second  week  of  the  puerperium  or  even  later.  In  most 
cases  the  first  manifestation  is  pain  in  one  leg  extending  along  the  course 
of  one  of  the  larger  veins;  this  is  soon  followed  by  oedema,  which  usually 
begins  in  the  foot  and  extends  upward,  although  occasionally  it  appears 
first  in  the  neighbourhood  of  the  groin.  The  leg  soon  becomes  much 
swollen,  the  skin  being  tightly  stretched  and  presenting  a  glazed  appear- 
ance, and  at  first  pitting  can  be  elicited  only  after  prolonged  pressure  with 
the  finger-tip.  If  the  crural  vein  is  implicated,  a  cord-like  structure,  which 
is  very  sensitive  to  pressure,  can  often  be  palpated  just  beneath  Poupart's 
ligament  and  for  a  certain  distance  down  the  thigh. 

The  inflammatory  changes  are  usually  attended  by  some  elevation  of 
temperature,  the  pulse  being  more  or  less  accelerated.  High  fever  and  a 
very  rapid  action  of  the  heart  usually  indicate  that  a  similar  process  is 
taking  place  in  other  portions  of  the  body,  and  that  the  patient  is  suffer- 
ing from  a  general  infection  or  pyaemia.  The  pain,  swelling,  and  tem- 
perature continue  for  several  weeks,  and  then  gradually  subside,  though 
occasionally  months  elapse  before  the  patient  regains  the  full  use  of 
the  leg. 

Ordinarily,  the  process  is  limited  to  one  side,  more  rarely  both  ex- 
tremities are  affected,  an  interval  of  a  week  or  ten  days  elapsing  before  the 
second  leg  becomes  implicated.  If  properly  treated,  most  cases  undergo 
spontaneous  cure,  the  condition  being  dangerous  only  when  it  forms  part  of 
a  generalized  infection,  or  when  the  thrombus  undergoes  suppuration  and 
softening,  so  that  infected  particles  are  carried  to  other  parts,  giving  rise 
to  metastatic  abscesses  and  occasionally  to  sudden  death  from  pulmonary 
embolism. 

Treatment.— Perfect  rest  is  absolutely  essential.  The  lower  part  of  the 
leg  should  be  elevated,  and  the  entire  member  encased  in  absorbent  cotton 
and  protected  from  the  weight  of  the  bedclothes  by  a  suitable  contrivance. 
If  the  pain  is  severe  morphine  may  be  required,  though  ordinarily  the  appli- 
cation along  the  course  of  the  thrombosed  vein  of  cloths  soaked  in  lead 
water  and  opium  is  followed  by  marked  relief.  Excellent  results  have  been 
reported  from  painting  the  leg  with  a  15-  or  20-per-cent  solution  of  ichthyol. 

On  account  of  the  danger  of  detaching  portions  of  the  thrombus,  the 
leg  should  never  be  rubbed.  The  patient  should  be  kept  in  a  horizontal 
position  for  at  least  a  week  after  the  pain  has  disappeared  and  the  tempera- 
ture subsided,  and  after  being  allowed  to  get  up  she  should  be  cautioned 
against  making  sudden  movements. 

Small  varicose  veins  of  the  lower  extremities  sometimes  undergo  throm- 
bosis during  pregnancy,  but  more  often  during  the  first  weeks  of  the  puer- 


DISEASES  OF   THE    URINARY   TRACT  799 

perium.  In  pregnancy  this  occurrence  is  favoured  b}r  the  interference  with 
the  circulation  due  to  the  pressure  exerted  by  the  uterus  upon  the  vessels 
returning  Prom  the  extremities.  During  the  puerperium  its  development  is 
occasionally  favoured  by  pressure  exerted  upon  the  intrapelvic  veins  by 
in  Ha  i  ii  ma  lory  exudates.  In  small  veins  the  thrombosis  is  usually  unattended 
by  symptoms,  although  now  and  again  the  development  of  a  localized  phle- 
bitis or  periphlebitis  may  cause  pain,  and  exceptionally  eventuate  in  the 
formation  of  a  small  localized  abscess. 

Gangrene  of  the  Lower  Extremities. — In  very  rare  instances,  as  the  re- 
sult of  extensive  thrombosis  of  the  venous  channels  or  of  embolism  of  the 
crural  artery,  the  circulation  in  the  foot  and  ankle  may  become  so  impaired 
that  gangrene  results.  One  or  both  feet  may  be  affected  in  this  way.  This 
accident,  first  described  by  Churchill  and  studied  more  particularly  by 
Wormser  and  Burckhard,  is  one  of  the  most  serious  complications  of  the 
puerperium,  and  usually  ends  fatally.  Thus,  62  per  cent  of  the  34  patients 
mentioned  in  Lafond's  thesis  died,  in  spite  of  the  fact  that  in  several 
instances  amputation  was  resorted  to  in  order  to  check  the  further  devel- 
opment of  the  process. 

Diseases  of  the  Urinary  Tract. — A  cystitis  occurring  during  the  puer- 
perium is  usually  the  result  of  infection  following  catheterization,  during 
which  the  rules  of  asepsis  have  not  been  scrupulously  followed.  The  occur- 
rence of  the  condition  is  favoured  by  the  presence  of  slight  lesions  of  the 
vesical  mucosa  which  frequently  accompany  easy  and  spontaneous  labours, 
and  are  almost  universally  associated  with  difficult  deliveries. 

In  view  of  the  impossibility  of  thoroughly  disinfecting  the  vulva  and 
urethral  orifice,  cystitis  will  occasionally  occur,  despite  the  most  rigid  pre- 
cautions. For  this  reason  catheterization  should  be  restricted  to  the  great- 
est possible  extent,  and  employed  only  in  those  cases  in  which  the  patient 
is  unable  to  evacuate  her  bladder  after  being  placed  in  a  sitting  position. 
In  rare  instances,  the  affection  results  from  the  direct  extension  of  areas 
of  inflammation  about  the  urethral  orifice  and  vulva. 

As  the  process  demands  a  certain  period  of  incubation,  s}Tnptoms  do  not 
usually  appear  for  several  days.  The  patient  first  experiences  a  frequent 
desire  to  micturate,  but  passes  only  a  small  quantity  of  urine  at  one  time, 
the  act  being  accompanied  by  a  burning  sensation  in  the  urethra  and  a 
tendency  to  tenesmus  after  each  evacuation.  At  the  same  time,  the  bladder 
and  the  urethra  become  sensitive  on  pressure.  The  urine  is  usually  cloudy, 
and  upon  microscopic  examination  is  found  to  be  loaded  with  mucus,  leu- 
cocytes, epithelial  cells,  and  bacteria.  Occasionally  it  contains  a  large  pro- 
portion of  blood.  The  acid  reaction  is  usually  retained,  although,  more 
especially  when  the  process  is  prolonged,  the  secretion  may  become  alkaline, 
and  very  offensive  in  odour. 

Xow  and  again  cases  are  encountered  in  which  the  infection  is  so  severe 
that  larger  or  smaller  portions  of  the  mucosa  become  exfoliated  and  are  cast 
off  with  the  urine,  their  expulsion  being  associated  with  cramp-like  pains. 

In  these  virulent  types,  and  also  in  the  milder  but  obstinate  processes,  the 
disease  tends  to  extend  up  the  ureters  and  to  involve  the  pelvis  of  the  kid- 
ney, giving  rise  to  a  pyelo-nephrosis  or  even  a  pyelo-nepliritis.  though  several 


800  OBSTETRICS 

weeks  are  usually  required  for  the  development  of  these  latter  conditions. 
Thus,  in  some  cases  the  patient  who  has  previously  had  a  cystitis,  but 
has  recovered  satisfactorily  from  the  puerperium,  may  suddenly' experience 
intense  pain  in  one  renal  region,  associated  with  the  development  of  a  tem- 
perature characterized  by  marked  remissions  and  the  passage  of  large  quan- 
tities of  urine  laden  with  pus.  The  condition  not  infrequently  apparently 
passes  off,  to  recur  again  when  least  expected. 

In  mild  cases  of  cystitis  the  treatment  consists  in  the  ingestion  of  large 
quantities  of  fluids,  particularly  milk  and  the  carbonated  and  alkaline 
waters.  The  vesical  irritability  is  often  satisfactorily  allayed  by  the  admin- 
istration of  the  various  balsams,  such  as  copaiba  or  sandalwood,  3  to  5  drops 
in  capsules  or  upon  a  lump  of  sugar  4  times  a  day,  or  by  the  exhibition 
of  5-grain  capsules  of  salol  or  urotropin  repeated  every  four  to  six  hours. 
Ordinarily,  simple  treatment  leads  to  recovery  in  a  comparatively  short 
time,  but  if  the  process  drags  on,  daily  irrigation  of  the  bladder  with  a  2- 
per-cent  solution  of  boric  acid  or  a  l-to-20,000  or  30,000  solution  of  bichlo- 
ride should  be  practised. 

Most  cases  of  j)yelo-nephrosis  recover  spontaneously  after  rest  in  bed 
and  the  administration  of  large  quantities  of  fluids  and  the  usual  renal 
antiseptics;  but  whenever  a  pyelo-nephritis  develops  and  is  accompanied  by 
prolonged  febrile  manifestations,  drainage  and  occasionally  extirpation  of 
the  organ  becomes  necessary. 

Retention  of  Urine. — In  Chapter  XVI,  upon  the  care  of  the  patient  dur- 
ing the  puerperium,  reference  was  made  to  the  retention  of  urine,  which 
frequently  causes  annoyance  during  the  first  few  days  of  that  period. 

Incontinence  of  Urine. — In  multiparous  women,  for  the  first  few  days  of 
the  puerperium,  coughing,  sneezing,  or  other  factors  leading  to  a  sudden 
increase  in  the  intra-abdominal  pressure,  often  }3roduce  an  involuntary  dis- 
charge of  a  small  quantity  of  urine. 

More  marked  incontinence  at  this  time  is  usually  the  result  of  lesions 
about  the  neck  of  the  bladder  following  operative  delivery,  though  when 
the  condition  does  not  manifest  itself  until  the  end  of  the  first  week  it  is 
usually  the  first  sign  of  the  development  of  a  vesico-vaginal  fistula.  In 
the  majority  of  such  cases  scrupulous  attention  to  cleanliness  will  be  fol- 
lowed by  spontaneous  recovery;  but  when  the  fistulous  opening  is  extensive, 
a  cure  can  be  effected  only  by  operative  procedures  at  a  later  period. 

Haemorrhages  during  the  Puerperium. — Ordinarily,  if  there  has  been  no 
serious  loss  of  blood  during  the  first  hour  or  hour  and  a  half  following 
delivery,  it  may  be  assumed  that  the  danger  of  post-partum  hemorrhage 
has  practically  passed,  and  that  the  only  loss  of  blood  for  the  next  few  days 
will  be  represented  by  the  lochial  discharge. 

Occasionally,  however,  in  the  latter  part  of  the  first  week,  and  more 
often  still  later  in  the  puerperium,  more  or  less  severe  uterine  haemor- 
rhages are  encountered.  They  are  nearly  always  due  to  the  retention  of 
portions  of  a  placental  cotyledon  or  of  a  succenturiate  lobule  which  may 
not  have  been  discovered  at  the  time  of  labour  in  spite  of  the  most  rigid 
precautions;  although  the  presence  of  large  portions  of  placenta  can  hardly 
be  overlooked  unless  the  obstetrician  is  grossly  negligent.     If  the  retained 


il.K.MoKUilAUKs   DURING   THE   PUERPERIUM  801 

tissue  is  not  cast  off  spontaneously  or  removed,  ii  undergoes  gradual  necro- 
sis, while  .it  the  same  time  fibrin  becomes  deposited  about  its  periphery, 
giving  rise  to  a  polypoid  growth  of  varying  size — placental  polyp — a  certain 
amount  of  haemorrhage,  although  not  enough  to  cause  alarm,  continuing 

;i-  lung  as  it  remains  in  the  uterus. 

Large  portions  of  the  foetal  membranes  retained  in  the  uterine  cavity 
rarely  give  rise  to  serious  hemorrhage,  as  the  tissues  gradually  disintegrate 
and  are  cast  off  with  the  lochial  discharge.  The  presence  of  a  remnant  of 
decidua  of  any  considerable  size  which  has  failed  to  undergo  the  usual 
regressive  changes,  may  act  as  an  irritant  upon  the  regenerating  endome- 
trium, giving  rise  to  a  hyperplasia  which  is  usually  associated  with  more 
or  less  haemorrhage.  This  condition  is  designated  as  endometritis  post-par- 
turn  or  post-abortion,  according  as  it  follows  full-term  labour  or  abortion. 

The  diagnosis  of  the  retention  of  a  placental  remnant  or  the  existence 
of  a  polyp  can  only  be  verified  by  the  sense  of  touch.  Therefore,  whenever 
a  patient  suffers  from  an  acute  loss  of  blood  during  the  puerperium,  the 
interior  of  the  uterus  should  be  carefully  palpated,  and  any  abnormal  sub- 
stance found  in  it  should  be  promptly  removed  by  means  of  the  finger  or 
curette. 

The  treatment  of  the  slight  hemorrhage  following  retroflexion  and  sub- 
involution of  the  uterus  will  be  referred  to  under  those  headings.  The 
loss  of  blood  associated  with  an  endometritis  post-partum  also  demands 
curettage.  If  the  patient  does  not  begin  to  bleed  until  late  in  the  puer- 
permm,  and  more  particularly  after  the  expulsion  of  an  hydatidiform  mole, 
the  possibility  of  the  existence  of  a  deciduoma  malignum  should  always  be 
considered.  "Wlienever  possible,  the  tissues  obtained  by  curetting  should 
be  submitted  to  microscopical  examination,  since  in  this  way  one  receives 
timely  warning  of  the  existence  of  any  serious  process. 

Puerperal  Hematoma. — A  tumefaction  resulting  from  the  escape  of 
blood  into  the  connective  tissue  beneath  the  vaginal  mucosa  or  the  skin 
covering  the  external  genitalia  is  known  as  a  vaginal  or  vulval  luptnatoma. 
This  condition,  first  studied  in  detail  by  Deneux,  in  1830,  is  a  rare  com- 
plication of  labour  and  the  puerperium,  occurring  about  once  in  1,500  or 
2,000  cases.  It  occasionally  originates  during  pregnancy,  but  more  often 
follows  injury  to  a  blood-vessel  during  the  act  of  labour  without  laceration 
of  the  superficial  tissues.  Xow  and  again  it  does  not  occur  until  later,  and 
is  then  attributable  to  the  sloughing  of  a  vessel  which  has  become  necrotic 
as  the  result  of  prolonged  pressure. 

The  site  at  which  the  hematoma  develops  varies  according  as  the  torn 
vessel  lies  beneath  or  above  the  pelvic  fascia.  In  the  former  case  the 
tumefaction  involves  the  vulva  and  perineal  region,  while  in  the  latter  it 
protrudes  into  the  vaginal  canal,  and  as  it  increases  in  size  separates  the 
peritoneum  from  the  underlying  tissues,  so  that  at  times  the  hematoma 
gradually  extends  up  into  the  false  pelvis. 

If  the  tumour  is  large,  it  not  only  causes  discomfort  by  its  mere 
size,  but  gives  rise  to  great  suffering-,  which  becomes  more  intense  the 
more  rapidly  it  is  formed,  as  the  result  of  the  tearing  and  stretching  of  the 
tissues.    In  rare  instances,  such  large  quantities  of  blood  may  be  contained 


802  OBSTETRICS 

in  the  hematoma  that  the  j>atient  suffers  from  an  acute  anaemia,  and  should 
the  mass  rupture  into  the  peritoneal  cavity  or  through  the  external  cover- 
ing, a  profuse  external  haemorrhage  may  occur  which  sometimes  proves 
fatal.  On  the  other  hand,  a  haematoma  of  a  moderate  size  is  usually  ab- 
sorbed spontaneously.  In  other  cases  the  tissues  covering  the  tumour  may 
undergo  pressure  necrosis  and  give  way,  profuse  haemorrhage  resulting, 
or  the  contents  may  be  discharged  in  the  form  of  large  clots.  In  either 
event  the  interior  of  the  haematoma  is  very  prone  to  become  infected,  the 
condition  sometimes  ending  fatally. 

A  vulval  haematoma  is  readily  diagnosed  by  the  sudden  appearance  at 
the  vulva  of  a  tense,  elastic,  fluctuating,  and  sensitive  tumour  of  varying 
size,  covered  by  the  discoloured  skin.  When  the  mass  develops  in  the 
vagina  it  may  escape  detection  for  a  time,  but  pressure  symptoms  soon 
ensue,  and  on  a  vaginal  examination  one  discovers  a  round,  fluctuant  tumour 
which  encroaches  upon  the  lumen.  On  the  other  hand,  when  a  haematoma 
extends  upward  between  the  folds  of  the  broad  ligament,  it  is  liable  to  escape 
detection,  unless  symptoms  of  anaemia  or  infection  appear.  In  such  cases 
careful  palpation  reveals  the  presence  of  a  rounded  tumour  mass  to  one 
side  of  the  uterus;  although  if  the  patient  is  not  seen  until  after  infection 
has  occurred,  the  differential  diagnosis  between  such  a  condition  and  a 
pelvic  inflammatory  mass  becomes  difficult. 

The  prognosis  is  usually  favourable,  though  very  large  haematomata  occa- 
sionally lead  to  death  from  haemorrhage,  whereas  in  rare  cases  the  fatal 
termination  is  the  result  of  infection. 

Treatment. — Small  haematomata  should  be  left  alone,  as  spontaneous  re- 
sorption usually  takes  place,  provided  the  parts  be  kept  clean  and  infection 
avoided.  On  the  other  hand,  since  a  steady  increase  in  the  size  of  the 
swelling  indicates  a  continuance  of  haemorrhage,  the  tumour  in  such  cases 
should  be  laid  widely  open  and  packed  with  gauze,  which  usually  effectually 
controls  the  loss  of  blood.  The  strictest  antiseptic  precautions  are  impera- 
tive, inasmuch  as  infection  is  a  frequent  complication. 

Diseases  and  Abnormalities  of  the  Uterus. — Subinvolution.— This  term 
is  used  to  describe  an  arrest  or  retardation  of  the  process  of  involution,  by 
which  the  puerperal  uterus  should  be  gradually  restored  to  its  original  pro- 
portions. 

Normal  involution  is  to  be  attributed  to  atrophy  of  the  individual  mus- 
cle cells  rather  than  to  fatty  degeneration,  as  was  formerly  supposed.  Its 
proximate  cause  is  to  be  sought  in  the  sudden  and  marked  diminution  of 
the  blood  supply  to  the  uterus;  and,  as  this  can  be  brought  about  only  by 
satisfactory  contraction  and  retraction  of  the  organ,  it  is  apparent  that  any 
interference  with  the  process  may  be  followed  by  subinvolution. 

Among  the  most  frequent  aetiological  factors  in  its  production  are 
inrp^rfe£t_exf^Hation  of  the  decidua,  retention  of  pjn;tions_  of  the  after- 
birth,. infljmnnatoryT^^  the  presence  of  myomatous 
nodules  in  th^uTerme  wail,"  abnormalities  of  circulatiorTwhich  frequently 
accompany  displacements  of  the  uterus,  the  existence  of  pelvic  inflamma- 
tory lesions,  and  insufficient  rest  daring  the  puerperiUm.  In  other  words, 
subinvolution  is  practically  always  the  result  of  local  conditions  and  not 


DISEASES  AND  ABNORMALITIES  OF  THE   DTERUS  803 

of  constitutional  disorders,  and  accordingly  careful  invesl  igal  ion  will  nearly 
always  reveal  the  underlying  cause,  and  appropriate  treatment;  if  under- 
taken sufficiently  early,  will  Lead  to  its  cuvf. 

The  existence  of  subinvolution  is  manifested  by  a  prolongation  of  the 
lochial  discharge  beyond  the  usual  period,  its  cessation  being  followed  by  a 
persistent  leucorfncea  and  pains  in  the  back,  a  general  feeling  of  draggi- 
ness.  and  a  delayed  return  to  perfect  health.  Similar  symptoms  accom- 
pany uterine  displacements,  but  in  all  probability  arc  in  great  part  due  to 
the  coincident  subinvolution. 

The  diagnosis  is  established  by  bimanual  examination,  the  uterus  being 
found  to  be  larger,  softer,  and  more  succulent  tban  it  should  be  at  a  given 
time  following  delivery.  Normally  the  fundus  should  have  descended  to 
the  level  of  the  upper  margin  of  the  symphysis  by  the  tenth  day  of  the 
puerperium,  although  the  organ  does  not  regain  its  original  size  for  six 
weeks  or  more  after  delivery. 

Inasmuch  as  subinvolution  is  dependent  mainly  upon  local  conditions, 
very  little  can  be  expected  from  medicinal  treatment,  although  the  admin- 
istration of  20  drops  of  the  fluid  extract  of  ergot  every  three  or  four 
hours  for  several  days  is  sometimes  followed  by  improvement.  Local  meas- 
ures afford  much  better  results.  If  the  uterus  is  displaced  it  should,  be 
put  in  proper  position  hj  bimanual  manipulation  and  held  in  position  by  a 
suitably  fitting  pessary.  When  disease  of  the  endometrium  or  retention 
of  portions  of  theaftcr-birth  are  responsible,  prompt  curettage  offers  the 
most  efficient  method  of  treatment.  On  the  other  hand,  procrastination  may 
lead  to  serious  results,  as  the  subinvolution  may  become  permanent,  and 
prove  a  constant  source  of  irritation. 

Lactation  Atrophy  of  the  Uterus. — Occasionally,  in  women  who  suckle 
their  children,  the  uterus  may  undergo  excessive  involution,  becoming 
smaller  than  in  the  virginal  state.  This  condition,  which  usually  becomes 
most  marked  during  the  third  or  fourth  month  after  delivery,  is  attributed 
to  reflex  irritation  emanating  from  the  breasts  and  incident  to  lactation 
and  nursing.  It  usually  disappears  spontaneously  after  weaning,  though 
when  the  child  is  nursed  for  a  longer  period  than  usual  the  uterus  may 
begin  to  increase  in  size  before  the  end  of  a  year,  even  though  lactation 
be  continued.  It  is  probable  that  the  cessation  of  menstruation,  which  is 
usually  observed  during  lactation,  should  be  attributed  to  this  form  of 
atrophy. 

The  condition  was  first  definitely  described  by  Jacquet,  in  1871,  and 
since  the  publication  of  his  paper  has  been  carefully  studied  by  numerous 
investigators,  particularly  Thorn,  Gottschalk,  Doderlein,  and  Vineberg. 

In  rare  instances  the  atrophy  may  persist  after  weaning  and  become  per- 
manent, the  uterine  cavity  sometimes  measuring  only  a  few  centimetres  in 
length.  This  abnormality,  first  described  by  Chiari,  Braun,  and  Spaeth,  in 
1855,  was  later  designated  by  Simpson  as  superinvolution.  It  is  probable 
that  it  may  occasionally  be  the  causative  factor  in  the  unusually  early  ap- 
pearance of  the  menopause. 

Displacements  of  the  Uterus. — Immediately  following  the  birth  of  the 
child,  the  lower  uterine  segment  and  cervix  are  represented  by  a  flabby, 


804  OBSTETRICS 

collapsed  structure  which  is  freely  movable  upon  the  rest  of  the  organ  (see 
Fig.  304).  Under  these  circumstances  a  comparatively  trivial  cause,  such 
as  a  slight  increase  in  the  intra-abdominal  pressure  or  distention  of  the 
rectum,  may  lead  to  a  bending  over  of  the  upper  part — anteflexion  of  the 
uterus.  The  condition  is  usually  without  significance,- but  occasionally  the 
angle  formed  between  the  upper  and  lower  portions  of  the  organ  may  be  so 
acute  as  to  occlude  the  cervical  canal  and  lead  to  the  retention  of  the  lochial 
discharge — locliiometra.  As  a  rule,  the  retention,  when  it  occurs,  is  only 
transitory,  but  if  it  be  prolonged  the  lochia  may  undergo  putrefactive 
changes  which  are  accompanied  by  the  formation  of  toxines,  the  absorp- 
tion of  which  may  give  rise  to  constitutional  symptoms.  The  complication 
is  readily  overcome  by  allowing  the  retained  discharge  to  drain  away 
through  a  douche-tube,  after  which  the  uterine  cavity  should  be  irrigated 
with  sterile  salt  solution. 

So  long  as  the  body  of  the  uterus  lies  above  the  promontory  of  the 
sacrum,  retrodisplacement  cannot  occur,  as  the  falling  backward  of  the 
enlarged  fundus  is  prevented  by  the  convex  surface  offered  by  the  lumbar 
vertebrae.  But  as  soon  as  the  organ  has  descended  into  the  pelvic  cavity 
a  retroflexion  or  retroversion  immediately  becomes  possible.  Their  develop- 
ment is  occasionally  favoured  by  the  use  of  an  abdominal  binder  which 
may  cause  the  abdominal  contents  to  exert  pressure  upon  the  fundus  of  the 
uterus,  forcing  it  downward  and  backward.  More  often  the  retroflexion 
merely  represents  a  recurrence  of  a  similar  condition  existing  prior  to  preg- 
nancy, while  in  other  cases  it  may  be  the  result  of  extreme  distention  of 
the  bladder.  Not  uncommonly  its  mode  of  production  is  difficult  to  un- 
derstand. 

Backward  displacements  of  the  uterus  rarely  give  rise  to  symptoms  so 
long  as  the  patient  remains  in  bed,  but  as  soon  as  she  begins  to  move  about 
their  presence  is  apt  to  cause  more  or  less  inconvenience.  The  earliest 
and  most  characteristic  manifestation  is  a  marked  increase  in  the  amount 
of  lochial  discharge  or  the  reappearance  of  the  flow  if  it  has  already  ceased. 
Sometimes  the  patient  suffers  from  pain  in  the  back  and  lower  abdomen, 
although  in  other  cases  she  may  only  be  conscious  that  she  is  not  regaining 
her  strength  as  rapidly  as  she  had  expected. 

The  presence  of  these  symptoms  should  always  suggest  the  existence  of 
a  retroflexion,  although  they  are  sometimes  due  to  subinvolution  produced 
by  other  causes.  A  positive  diagnosis  can  always  be  made  upon  vaginal 
examination. 

The  restoration  of  the  uterus  to  its  normal  position  by  bimanual  manip- 
ulations, and  the  introduction  of  a  properly  fitting  pessary,  as  a  rule 
will  afford  prompt  relief,  and  on  removal  of  the  pessary  some  months 
later  it  will  usually  be  found  that  a  permanent  cure  has  resulted.  On 
the  other  hand,  if  its  employment  is  postponed  too  long  much  less  favour- 
able results  are  obtained.  This  fact  serves  again  to  emphasize  the  neces- 
sity for  making  a  final  examination  before  discharging  the  puerperal 
patient.  When  the  patient  has  suffered  from  retroflexion  before  preg- 
nancy, an  examination  made  at  the  end  of  the  second  week  of  the  puer- 
perium  will  usually  show  that  the  uterus  has  returned  to  its  abnormal 


OBSTETRICAL  PARALYSIS 

position.  In  such  cases  it  should  be  replaced  and  a  pessary  at  once 
int  roduced. 

Relaxation  of  tin-  Vaginal  Outlet  and  Prolapse  of  the  ['/cms. —  Reference 
lias  already  been  made  to  the  Erequenl  occurrence  of  perineal  lacerations  at 
the  time  of  labour  and  the  consequent  relaxation  of  the  vaginal  outlet 
which  follows  neglect  to  repair  them. 

Moreover,  the  changes  following  childbearing  predispose  to  the  occur- 
rence  of  prolapse  of  the  n/crus,  and  an  exacerbation  should  be  expected 
during  the  puerpefium  in  women  who  have  presented  moderate  degrees  of 
descensus  uteri  before  labour.  In  order  to  obtain  the  best  results,  and  to 
prevent  serious  disability,  an  early  operation  is  imperative,  since  the  diffi- 
culty of  rectifying  the  condition  depends  largely  upon  the  extent  of  the 
prolapse  and  the  length  of  time  that  it  has  been  allowed  to  exist. 

Obstetrical  Paralysis. — Paralytic  conditions  may  develop  in  either 
mother  or  child  during  the  puerperium.  That  branches  of  the  sacral  plex- 
us sometimes  suffer  from  pressure  during  labour  is  demonstrated  by  the 
fact  that  many  patients  complain  of  intense  neuralgia  or  of  cramp-like 
pains  extending  down  one  or  both  legs  as  soon  as  the  head  begins  to  descend 
into  the  pelvic  canal.  As  a  rule,  of  course,  the  compression  is  rarely  severe 
enough  to  give  rise  to  grave  lesions.  In  some  instances,  however,  the  pain 
continues  after  delivery,  and  is  accompanied  by  the  development  of  paraly- 
sis in  the  muscles  supplied  by  the  external  popliteal  nerve — the  flexors  of 
the  ankles  and  the  extensors  of  the  toes — the  gluteal  muscles  occasionally 
becoming  affected  to  a  lesser  extent. 

The  subject  has  been  carefully  studied  by  Hiinermann  and  IT.  M. 
Thomas.  The  investigations  of  the  former  supplied  a  very  satisfactory  ex- 
planation of  the  common  localization  of  the  paralysis  by  showing  that  the 
external  popliteal  nerve  receives  fibres  from  the  fourth  and  fifth  lumbar 
roots,  and  that  these  on  their  way  downward  to  join  the  sacral  plexus  pass 
over  the  brim  of  the  pelvis,  where  they  are  exposed  to  danger  from  com- 
pression, whereas  the  lower  roots  which  lie  upon  the  pyriformis  muscle  are 
more  protected. 

Hiinermann  considers  that  the  chances  of  injurious  pressure  are  great- 
est where  the  pelvis  is  generally  contracted,  and  less  so  in  the  rhachitic 
varieties,  inasmuch  as  the  projecting  promo ntory  in  the  latter  tends  to  pre- 
vent the  head  from  coming  in  contact  with  the  nerve.  In  the  majority  of 
cases  the  injury  is  the  result  of  direct  pressure  exerted  by  the  child's  head, 
and  only  exceptionally  is  caused  by  the  forceps. 

In  view  of  the  fact  that  only  one  oblique  diameter  of  the  superior  strait 
is  occupied  by  the  greatest  diameter  of  the  head,  it  is  readily  understood 
why  the  paralysis  is  usually  limited  to  one  leg,  Thomas's  case  being  the 
only  instance  on  record  in  which  both  legs  were  affected.  The  paralytic 
symptoms  usually  appear  immediately  after  delivery,  and  may  become  per- 
manent unless  suitable  therapeutic  measures,  more  particularly  the  use  of 
electricity,  are  promptly  instituted. 

In  other  cases  paralytic  symptoms  accompanied  by  intense  neuralgic 
pains  following  the  course  of  the  sciatic  nerve,  follow  pelvic  inflammatory 
troubles.    The  condition  is  sometimes  due  to  the  development  of  a  neuritis 


806  OBSTETRICS 

affecting  certain  branches  of  the  sacral  plexus,  while  in  other  cases  pressure 
exerted  by  an  inflammatory  exudate  is  responsible.  I  have  seen  a  case  of 
the  latter  character  which  persisted  for  years  in  spite  of  continuous  treat- 
ment, and  which  disappeared  as  if  by  magic  after  laparotomy  and  the  sepa- 
ration of  the  adherent  appendages  from  the  posterior  and  lateral  portions 
of  the  pelvic  wall. 

Winscheid  has  directed  particular  attention  to  the  rare  cases  of  neuritis 
which  follow  delivery.  The  inflammation  may  be  general  or  localized.  In 
the  latter,  only  one  or  two  nerves  are  affected — the  median,  ulnar,  or  crural 
— and  atrophic  symptoms  soon  make  their  appearance.  In  the  former, 
since  a  number  of  nerves  are  implicated  simultaneously,  sometimes  even 
those  of  the  face  not  escaping,  the  symptoms  may  be  manifold  and  the 
condition  become  most  serious.  In  either  event  we  are  ignorant  concerning 
the  mode  of  production  of  the  nerve  lesions,  though  they  are  supposed  to 
be  due  to  toxic  influences.  The  prognosis  is  fair  for  the  localized  but 
poor  for  the  generalized  variety. 

It  is  also  important  to  bear  in  mind  that  separation  of  the  symphysis 
pubis,  or  of  one  or  other  sacro-iliac  synchondrosis  during  labour,  may  be 
followed  by  pain  and  so  marked  an  interference  with  locomotion  as  at  first 
sight  to  suggest  the  existence  of  paralysis.  Moreover,  the  disturbances  in 
the  function  of  the  psoas  muscles  and  the  adductors  of  the  thigh,  which  so 
frequently  accompany  the  early  stages  of  osteomalacia,  might  readily  lead 
to  a  similar  error. 

As  a  result  of  a  difficult  labour,  and  exceptionally  after  an  easy  one,  the 
child  is  sometimes  born  presenting  an  affection  of  the  arm  which  is  com- 
monly known  as  Duchenne's  paralysis.  In  this  form,  paralysis  of  the  deltoid, 
infraspinatus,  and  the  flexor  muscles  of  the  forearm  causes  the  entire  arm 
to  fall  close  to  the  side  of  the  body,  and  at  the  same  time  to  rotate  inward, 
while  the  forearm  becomes  extended  upon  the  arm.  The  motility  of  the 
fingers  is  usually  retained. 

Erb  pointed  out  that  such  a  paralysis  could  be  due  only  to  a  lesion 
involving  the  fifth  and  sixth  roots  of  the  brachial  plexus,  and  showed 
that  electrical  stimulation  at  a  point  from  2  to  3  centimetres  above  the 
clavicle  and  in  front  of  the  transverse  process  of  the  sixth  cervical  vertebra 
—now  known  as  Erb's  point — produces  contractions  of  the  muscles  involved. 
He  considered  that  the  paralysis  frequently  follows  compression  of  the 
plexus  by  the  clavicle  in  the  Prague  method  of  extraction,  more  particu- 
larly when  the  arms  have  become  extended  over  the  head.  In  other  cases 
its  production  is  attributed  to  traction  with  the  fingers  in  the  axilla  of  the 
child,  and  occasionally  to  the  use  of  forceps. 

That  compression  may  be  exerted  during  the  employment  of  either  of 
the  first  two  of  these  manoeuvres  is  at  once  evident  from  a  consideration  of 
the  anatomical  relations.  On  the  other  hand,  the  experiments  of  Stolper 
show  that  the  plexus  cannot  possibly  be  compressed  by  the  tips  of  the  for- 
ceps so  long  as  the  child  presents  by  the  vertex,  although  it  may  occur  in 
face  or  brow  presentations. 

Carter,  in  1893,  was  the  first  to  direct  attention  to  the  fact  that  the 
condition  is  due  to  stretching  of  the  upper  roots  of  the  brachial  plexus 


DISEASES  AND   ABNORMALITIES  OF  THE    BREASTS  807 

more  frequently  than  bo  abnormal  pressure.  His  results  were  confirmed 
by  tlic  experimental  work  oi'  I'ieux,  Schoemaker,  and  Slolper,  all  of  whom 
demonstrated  thai  the  plexus  was  readily  subjected  to  extreme  tension  as 
a  result  of  pulling  obliquely  upon  the  head,  thus  sharply  flexing  ii  towards 
one  or  other  shoulder.  As  traction  in  this  direction  is  frequently  employed 
in  order  In  effect  delivery  of  the  shoulders  in  vertex  presentations,  ii  is 
readily  seen  that  Duchenne's  paralysis  might  follow  comparatively  simple 
or  even  spontaneous  labours.  In  view  of  these  considerations,  therefore, 
in  extracting  the  shoulders  care  should  be  taken  not  to  bring  about  too 
ureal  lateral  flexion  of  the  neck.  Moreover,  in  breech  extractions  the 
Prague  manoeuvre  should  be  employed  only  when  absolutely  necessary,  and 
particular  attention  should  be  devoted  to  preventing  the  extension  of  the 
arms  over  the  head,  as  it  not  only  materially  complicates  delivery,  but  adds 
considerably  to  the  danger  of  infantile  paralysis. 

The  prognosis  is  usually  fair,  the  majority  of  the  children  recovering. 
Occasionally,  however,  a  case  may  resist  all  treatment  and  the  child  may 
remain  hopelessly  paralyzed.  All  of  the  five  instances  which  I  have  per- 
sonally observed  ended  in  recovery,  but  in  some  of  them  prolonged  treat- 
ment was  necessary.  In  this  form  of  paralysis  the  children  should  be 
promptly  put  under  the  care  of  a  competent  neurologist,  as  the  intelligent 
use  of  the  electrical  current  is  frequently  the  only  means  by  which  degen- 
erative changes  in  the  nerves  and  muscles  can  be  obviated,  and  neglect  in 
this  regard  may  result  in  the  condition  becoming  permanent. 

Abnormalities  and  Diseases  of  the  Breasts. — Complete  absence  of  both 
breasts  is  one  of  the  rarest  anomalies  of  development,  while  the  absence  of 
one  and  the  normal  development  of  the  other  breast  has  been  noted  in  a  few 
isolated  cases. 

Hypertrophy  of  Hie  breasts  is  more  frequently  observed,  but  is  neverthe- 
less an  infrequent  occurrence.  In  a  large  proportion  of  the  recorded  cases 
the  condition  developed  rapidly  in  young  unmarried  women,  both  breasts 
being  implicated  and  occasionally  attaining  such  immense  proportions  that 
amputation  became  necessary.  Cases  have  been  reported  in  which  a  single 
breast  weighed  more  than  50  pounds.  The  hypertrophy  sometimes  recedes 
during  lactation,  so  that  the  abnormality  does  not  always  afford  an  absolute 
contra-indication  to  suckling  the  child.  Overdevelopment  of  the  mamma'  is 
sometimes  observed  in  men,  a  number  of  cases  having  been  collected  by 
Laurent. 

Supernumerary  Breasts.— Vvohahly  one  in  every  few  hundred  women 
has  one  or  more  accessory  breasts — polymastia.  Reference  to  262  such  cases 
are  to  be  found  in  Goldberger's  article. 

The  supernumerary  breasts  rarely  attain  any  considerable  size,  and  oc- 
casionally are  so  minute  as  to  be  mistaken  for  small  pigmented  moles.  They 
are  usually  provided  with  distinct  nipples.  They  are  most  commonly  situ- 
ated upon  the  anterior  thoracic  or  abdominal  walls,  usually  near  the  mam- 
mary line;  less  frequently  they  are  found  in  the  axillae,  and  occasionally 
upon  other  portions  of  the  body — the  shoulder,  flank,  or  groin,  and  in  rare 
instances  the  thigh.  They  vary  greatly  in  number,  Keugebauer  having 
described  a  patient  with  10  breasts. 


808  OBSTETRICS 

The  condition  is  usually  regarded  as  an  atavistic  reversion,  though  it 
is  not  associated  with  an  increased  tendency  towards  multiple  pregnancy. 
In  not  a  few  instances  an  apparent  hereditary  influence  can  be  traced.  Not 
all  observers,  however,  accept  this  view,  Ahlfeld  holding  that  the  distribu- 
tion of  the  mammary  tissue  is  to  be  attributed  to  the  transference  at  an 
early  period  of  development  of  some  of  the  cells,  which  ordinarily  go  to 
form  the  breasts,  to  other  portions  of  the  body  by  means  of  the  amnion. 
The  condition  has  no  obstetrical  significance,  though  occasionally  the  en- 
largement of  supernumerary  breasts  occupying  the  axillae  may  result  in 
considerable  discomfort  to  the  patient. 

Abnormalities  of  the  Nipples. — The  typical  nipple  is  cylindrical  in  shape 
and  projects  well  beyond  the  general  surface  of  the  breast,  its  exterior 
being  slightly  nodular  but  free  from  fissures.  Variations  from  the  normal, 
however,  are  not  uncommon,  some  of  them  being  so  pronounced  as  to  inter- 
fere seriously  with  the  act  of  suckling. 

In  some  women  the  lactiferous  ducts  open  directly  into  an  area  which 
forms  a  depression  at  the  centre  of  the  areola.  In  pronounced  instances  of 
this  so-called  depressed  nipple,  nursing  is  out  of  the  question,  although 
when  the  depression  is  not  very  deep  the  breast  may  occasionally  be  made 
available  by  the  employment  of  a  nipple-shield. 

More  frequently,  although  not  depressed,  the  nipple  is  so  stunted  that 
it  hardly  project's  above  the  surface  of  the  breast,  and  in  consequence  can 
be  seized  by  the  child's  mouth  only  with  the  greatest  difficulty.  In  the 
presence  of  this  anomaly  daily  attempts  should  be  made  during  the  last  few 
months  of  pregnancy  to  draw  the  nipple  out  by  traction  with  the  fingers, 
and  a  wooden  nipple-shield  should  be  constantly  worn  in  the  hope  that  by 
exerting  pressure  upon  the  periphery  of  the  areola  the  nipple  itself  may 
be  gradually  made  to  protrude  through  the  opening  of  the  shield  (see 
Fig.  173). 

Again,  it  sometimes  happens  that  nipples  which  are  normal  in  shape 
and  size  may  present  so  fissured  or  nodular  a  surface  as  to  be  especially 
susceptible  to  injury  from  the  child's  mouth  during  the  act  of  nursing.  In 
such  cases  small  cracks  or  fissures  almost  inevitably  appear,  and  render 
nursing  so  painful  that  the  mother  dreads  the  approach  of  the  child,  and 
the  mental  distress  so  induced  often  has  a  deleterious  influence  upon  the 
secretory  function.  Moreover,  such  injuries  are  still  more  serious  in  that 
they  offer  a  convenient  portal  of  entry  for  pyogenic  bacteria  which  are  liable 
to  invade  the  breast  and  give  rise  to  a  mastitis. 

Abnormalities  in  the  Mammary  Secretion. — Marked  individual  variations 
exist  in  the  amount  of  milk  secreted,  many  of  which  are  dependent  not 
upon  the  general  health  and  appearance  of  the  individual,  but  upon  the 
degree  of  development  of  the  glandular  portions  of  the  breasts.  Thus  we 
often  find  that  a  woman  who  possesses  large,  well-formed  breasts,  and  who 
apparently  should  be  an  excellent  milk-producer,  secretes  only  a  small  quan- 
tity; while,  on  the  other  hand,  one  is  often  surprised  at  the  abundant  supply 
produced  by  another  whose  mamma?  are  small  and  flat.  It  is  a  matter  of 
common  observation  that  stout  women  with  well-formed  but  redundant 
breasts  usually  have  a  very  deficient  secretion,  the  bulk  of  the  organ  being 


DISEASES   AND   ABNORMALITIES   OF   THE    BREASTS  809 

made  up  orf  Tally  tissue  while  the  glandular  elements  arc  poorly  developed. 
Deficienl  secretion  is  likewise  frequently  noted  in  very  young  women  and 
in  elderly  priniipane.  In  (lie  former,  (lie  defect  is  to  be  attributed  to 
imperfect  development;  in  the  latter,  to  regressive  and  atrophic  changes  in 
the  breasts. 

Jn  very  rare  instances  there  is  an  absolute  lack  of  mammary  secretion — 
agalacia.  As  a  rule,  however,  the  defect  is  not  absolute,  as  it  is  nearly 
always  possible  to  cause  at  least  a  small  amount  to  exude  from  the  nipple 
on  the  third  or  fourth  day  of  the  puerperium.  On  the  other  hand,  rela- 
tive deficiency  is  frequently  observed,  a  large  number  of  women  secreting 
an  amount  of  milk  quite  insufficient  for  the  nutrition  of  the  child.  In 
Chapter  XVII  reference  was  made  to  the  variations  in  the  quantity  of  the 
milk  as  well  as  the  various  factors  which  may  be  concerned  in  their  pro- 
duction. 

Occasionally  the  mammary  secretion  is  excessive — polygalactia — and  may 
even  be  so  abundant  that  milk  is  constantly  escaping  from  the  nipples. 
This  latter  condition,  which  is  known  as  galactorrhcea,  sometimes  continues 
for  years  after  the  birth  of  the  child,  and  is  extremely  intractable  to  treat- 
ment. Nothing  is  known  as  to  its  cause.  Although  in  rare  instances  die 
health  of  the  woman  may  remain  unimpaired,  as  a  rule  she  soon  begins  to 
show  evidences  of  the  continuous  drain  upon  her  system,  becoming  irritable, 
querulous,  and  eventually  developing  symptoms  of  cachexia. 

Galactorrhcea  is  best  treated  by  the  application  of  tight  bandages  and 
the  internal  administration  of  fairly  large  doses  of  potassium  iodide.  Good 
effects  are  also  said  to  have  been  obtained  from  the  use  of  chloral.  In  a 
certain  number  of  cases  the  condition  is  combined  with  atrophy  of  the 
uterus,  and  several  observers  have  reported  improvement  following  pro- 
cedures which  tend  to  bring  about  an  increase  in  size  of  the  uterus,  such 
as  the  use  of  the  vaginal  douche,  local  applications  to  the  cervix,  or  the 
employment  of  electricity. 

Diseases  of  the  Nipples. — The  mode  of  production  and  treatment  of  fis- 
sures of  the  nipples  has  already  been  considered  in  detail  in  Chapter  XVII. 

Engorgement  of  the  Breasts. — For  the  first  twenty-four  or  forty-eight 
hours  following  the  development  of  the  lacteal  secretion,  it  is  not  unusual  for 
the  breasts  to  become  immensely  distended,  and  to  offer  on  palpation  a  firm, 
nodular  resistance.  This  condition,  which  is  commonly  known  as-"  caked 
breast,"  often  gives  rise  to  a  considerable  degree  of  pain,  and  is  frequently 
accompanied  by  a  slight  elevation  of  temperature.  Within  a  day  or  so  the 
engorgement  usually  passes  off  spontaneously  or  as  the  result  of  appropriate 
treatment,  though  in  some  cases  it  persists  in  spite  of  all  that  can  be  done, 
and  may  be  a  forerunner  of  the  development  of  a  mammary  abscess.  It  is 
probable  that  the  excessive  distention  of  the  glandular  portion  of  the  breast 
leads  to  slight  tissue  changes,  thereby  offering  a  locus  minoris  resistentiae 
for  invasion  by  bacteria,  which  are  usually  present  in  the  lactiferous 
ducts. 

Whenever  the  breast  becomes  markedly  engorged,  immediate  steps 
should  be  taken  to  relieve  the  condition.  This  is  most  readily  accom- 
plished by  evacuating  a  portion  of  its  contents.    When  the  child  is  unable 


810  OBSTETRICS 

to  draw  off  a  sufficient  quantity,  an  English  breast-pump  should  be 
employed  to  remove  the  excess.  In  many  cases,  however,  when  this  pro- 
cedure proves  ineffectual,  proper  massage  often  gives  immediate  relief. 
The  nurse  having  anointed  the  palmar  surfaces  of  her  hands  with  olive-oil, 
mixed  with  equal  parts  of  laudanum  if  the  breasts  are  very  sensitive,  makes 
stroking  movements,  beginning  at  the  periphery  of  the  breast  and  gradu- 
ally approaching  the  nipple.  At  first  the  manipulations  should  be  made 
very  gently,  but  as  the  patient  becomes  accustomed  to  them  more  force  may 
be  employed,  which  will  soon  cause  the  milk  to  exude  from  the  nipple. 
After  the  breast  has  been  emptied,  it  should  be  thickly  covered  with  cot- 
ton batting  and  firmly  compressed  against  the  thoracic  wall  by  means  of  a 
tightly  applied  bandage,  which  not  only  relieves  pain  by  preventing  the 
overloaded  organ  from  sagging  downward,  but  at  the  same  time  serves  to 
diminish  the  amount  of  secretion  by  diminishing  the  blood  supply. 

Occasionally  the  engorgement  persists  in  spite  of  all  that  can  be  done. 
In  such  cases,  if  several  days  of  persistent  effort  prove  unavailing,  the 
interests  of  the  patient  will  be  best  subserved  by  drying  up  the  breasts,  as 
a  continuance  of  the  condition  is  almost  sure  to  eventuate  in  abscess  for- 
mation. 

Inflammation  of  the  Breasts — Mastitis. — Parenchymatous  inflammation 
of  the  mammary  glands  is  a  not  infrequent  complication  of  the  puerperium. 
The  symptoms  hardly  ever  appear  before  the  end  of  the  first  week,  and  as 
a  rule  not  until  considerably  later.  Marked  engorgement  usually  precedes 
the  inflammatory  trouble,  the  first  sign  of  which  is  afforded  by  chilly  sen- 
sations or  an  actual  rigor,  which  is  soon  followed  by  a  considerable  rise  in 
temperature  and  an  increase  in  the  rate  of  the  pulse.  The  breast  becomes 
hard,  its  surface  is  reddened,  and  the  patient  complains  of  acute  pain.  In 
many  instances,  by  the  end  of  twenty-four  hours  the  condition  disappears 
spontaneously  without  treatment,  being  often  favourably  influenced  by  the 
application  of  a  tightly  fitting  bandage.  But  if  the  symptoms  persist  for 
longer  than  forty-eight  hours,  suppuration  is  to  be  expected.  The  process 
may  remain  limited  to  a  single  lobe  if  the  first  abscess  is  opened  promptly; 
but  if  left  to  itself  the  breast  is  liable  to  become  undermined  in  all  direc- 
tions, and  as  a  result  the  destruction  of  tissue  is  extensive,  and  the  exter- 
nal surface  may  be  left  riddled  with  numerous  fistulous  tracts. 

In  some  cases  the  constitutional  symptoms  attending  a  mammary  abscess 
are  very  marked,  whereas  the  local  manifestations  may  be  so  slight  as  to 
escape  observation.  Such  cases  are  usually  mistaken  for  puerperal  infec- 
tion, and  give  rise  to  no  little  anxiety  until  the  examination  of  cultures 
from  the  uterine  cavity  has  demonstrated  the  absence  of  bacteria.  On  the 
other  hand,  a  certain  number  of  cases  pursue  a  subacute  or  almost  chronic 
course,  the  breast  being  somewhat  harder  than  usual  and  more  or  less 
painful,  but  constitutional  symptoms  are  either  lacking  or  very  slight. 
Under  such  circumstances  the  first  indication  of  the  true  state  of  affairs  is 
often  afforded  by  the  detection  of  fluctuation. 

/Etiology. — Mastitis  is  always  the  result  of  infection,  pathogenic  bac- 
teria from  outside  gaining  access  to  the  breast  through  fissured  nipples 
by  way  of  the  lymphatics;  or  else  some  of  those  already  present  in  the 


DISEASES   AND   ABNORMALITIES  OF  THE   BREASTS  "11 

Lactiferous  ducts  meel  with  conditions  which  enable  them  to  invade  the 
tissues.  The  researches  of  Biimm,  Hbnigmann,  Koestlin,  and  others,  have 
demonstrated  that  Staphylococcus  albus  is  presenl  in  80  to  94  per  cent  of 
all  breasts.  Ordinarily,  this  micro-organism  live-  in  the  milk  a-  a  harm- 
less parasite,  Inn  when  the  tissues  are  seriously  altered  as  the  result  of  en- 
gorgement, it  is  possible  for  it  to  become  pathogenic.  That  this  occurs, 
however,  in  only  a  small  proportion  of  cases  has  been  .shown  by  t lie  re- 
searches  of  Rubeska,  who  reported  the  following  bacteriological  findings 
in  16  eases  of  mammary  abscess: 

Staphylococcus  aureus 9  cases 

Staphylococcus  aureus  and  albus 3     " 

Staphylococcus  albus 3     " 

Streptococcus 1  case 

Exceptionally,  other  bacteria  are  causative  agents,  Sarfert  having  demon- 
strated the  gonococcus  in  one  instance. 

When  the  infection  occurs  through  fissured  nipples,  the  inflammation 
is  usually  phlegmonous  in  character.  In  some  cases  it  involves  only  the 
connective  tissue  beneath  the  breast,  a  large  collection  of  pus  being  formed 
between  it  and  the  thoracic  wall — retromammary  abscess.  Again,  the  infec- 
tion may  be  limited  to  the  areola,  beneath  which  small  abscesses,  rarely 
exceeding  1.5  centimetre  in  diameter,  may  develop — subareolar  mastitis. 

According  to  TVinckel,  67.6  per  cent  of  all  cases  of  mastitis  occur  in 
primipara?,  but  its  actual  incidence  varies  according  to  the  care  given  the 
patients  during  pregnancy  and  the  puerperium.  Thus,  the  statistics  of 
Eubeska  show  a  frequency  of  0.54  to  4.1  per  cent  in  the  various  German 
clinics.  Generally  speaking,  it  may  be  said  that  the  occurrence  of  mastitis 
in  more  than  1  per  cent  of  a  large  series  of  cases  is  indicative  of  neglect  on 
the  part  of  the  physician  or  nurse. 

Treatment. — The  occurrence  of  mastitis  can  be  prevented  in  great  part 
by  suitable  prophylactic  measures,  which  mainly  consist  in  preventing  the 
development  of  fissured  nipples  or  treating  them  property  after  they  have 
appeared. 

The  most  suitable  measures  for  hardening  the  nipples  during  pregnancy 
so  as  to  enable  them  to  better  withstand  the  strain  of  nursing,  have  already 
been  mentioned  in  Chapter  XVII.  When  lactation  becomes  established 
the  strictest  cleanliness  should  be  observed  and  the  nipples  watched  most 
carefully.  As  soon  as  a  fissure  begins  to  develop  a  nipple-shield  should  be 
employed,  the  child  not  being  allowed  to  apply  the  mouth  directly  to  the 
nipple  until  healing  has  taken  place.  In  the  intervals  between  the  feedings 
the  sore  nipple  should  be  covered  with  a  clean  cloth  or  a  piece  of  absorbent 
cotton  soaked  in  a  saturated  solution  of  boric  acid.  The  various  applica- 
tions which  are  usually  recommended,  however  good  in  themselves,  will 
prove  practically  valueless  unless  the  nipple  can  be  placed  at  comparative 
rest,  which  is  best  afforded  by  the  use  of  a  suitable  nipple-shield.  If  the 
condition  becomes  worse  after  some  days'  trial  of  this  treatment,  it  is  ad- 
visable to  wean  the  child  rather  than  take  the  risk  of  infection  which  is 
so  prone  to  follow  if  the  deeply  fissured  nipple  be  used  for  any  length  of 


812  OBSTETEICS 

time.  Finally,  it  may  be  said  that  too  great  stress  cannot  be  laid  upon 
prompt  attention  to  engorgement  of  the  breasts,  as  its  prolonged  persist- 
ence is  nearly  always  followed  by  abscess  formation. 

'On  the  first  symptom  of  mammary  infection,  the  breast  should  be  put  at 
rest  as  far  as  possible  by  not  allowing  the  child  to  nurse  it,  and  withdrawing 
the  milk,  if  necessary,  by  means  of  a  breast-pump.  After  being  emptied 
the  breast  should  be  thickly  covered  with  cotton,  and  by  means  of  a  tightly 
fitting  bandage  subjected  to  the  greatest  possible  pressure  consistent  with 
the  comfort  of  the  patient.  In  many  cases  such  treatment  apparently  cuts 
short  the  process,  the  symptoms  disappearing  within  twenty-four  hours, 
after  which  the  patient  is  able  to  resume  suckling  her  child.  Usually, 
however,  the  process  sooner  or  later  eventuates  in  abscess  formation.  In 
such  cases  the  breasts  should  be  carefully  watched  and  incised  as  soon  as 
the  slightest  evidence  of  fluctuation  can  be  obtained.  Procrastination  is 
not  permissible,  delay  being  synonymous  with  extension  of  the  process, 
which  frequently  leads  to  such  extensive  destruction  of  tissue  as  to  per- 
manently destroy  the  physiological  function  of  the  organ. 

The  incisions  should  be  made  radially,  extending  from  near  the  areolar 
margin  towards  the  periphery  of  the  gland,  in  order  to  avoid  injury  to  the 
lactiferous  ducts.  In  early  cases,  a  single  incision  over  the  most  dependent 
portion  of  the  area  of  fluctuation  is  usually  sufficient,  but  when  multiple 
abscesses  are  present  several  incisions  may  be  required.  The  operation 
should  always  be  done  under  anaesthesia,  and  the  obstetrician  should  not 
consider  that  it  has  been  completed  until  he  has  introduced  a  finger  through 
the  incision  and  carefully  explored  the  interior  of  the  breast,  breaking  down 
the  partition  walls  between  the  various  pockets  of  pus,  so  that  only  a  single 
abscess  cavity  is  left  to  be  dealt  with.  This  should  then  be  loosely  packed 
with  gauze,  which  is  removed  at  the  end  of  twenty-four  hours  and  the  cavity 
washed  out  with  sterile  salt  solution  or  a  2-per-cent  boric-acid  solution, 
after  which  another  pack  is  inserted.  If  the  pus  has  been  thoroughly  evacu- 
ated the  abscess  cavity  becomes  obliterated  with  a  rapidity  which  is  some- 
times surprising. 

Galactocele. — Very  exceptionally,  as  the  result  of  clogging  of  a  milk  duct 
by  inspissated  secretion,  an  accumulation  of  milk  may  take  place  in  one  or 
more  lobes  of  the  breast.  Ordinarily,  this  is  limited  in  amount,  but  may 
become  excessive  and  form  a  fluctuant  tumour  which  may  give  rise  to 
pressure  symptoms.  In  many  instances,  massage  and  the  application  of  a 
tight  bandage  will  cause  it  to  disappear,  while  in  others  the  structure  may 
attain  such  a  size  that  puncture  becomes  imperative. 

Puerperal  Psychoses. — Eeference  has  already  been  made  to  the  altera- 
tions in  the  mental  condition  which  may  accompany  pregnancy.  These 
vary  from  slight  changes  in  disposition  to  actual  insanity,  though  fortu- 
nately the  latter  is  of  relatively  rare  occurrence. 

The  insanity  of  pregnancy  is  usually  a  mamfe^tajjon  of  autointoxica- 
J^an,  and  may  be  accompanied  by  melancholic  or  maniacal  symptoms.  It 
usually  persists  throughout  the  remainder  of  gestation,  but  disappears 
shortly  after  labour,  unless  the  patient  has  an  hereditary  tendency  to  mental 
derangement. 


PUERPERAL   INSANITY  813 

Puerperal  insanity,  on  the  other  hand,  is  much  more  common,  and 
according  to  the  statistics  compiled  by  Berkley  is  noted  once  in  every  616 
labours,  though  my  experience  would  lead  me  to  believe  it  less  frequent. 
In  former  limes  it  was  a  comparatively  common  complication  of  the  puer- 
perium,  and  it  would  seem  that  the  introduction  of  aseptic  methods  into 
midwifery  is  responsihle  for  a  reduction  hy  one  half  in  its  incidence. 

The  alfection  usually  makes  its  appearance  within  the  first  two  weeks 
following  delivery.  When  it  occurs  at  a  later  period  it  is  designated  as 
hifhitioiinl  instill  Hi/. 

Puerperal  psychoses  may  be  due  to  one  of  three  causes:  imfectim^auto^ 
intoxication,  or  direct  lability  of__the_ncrvous  system.  Ofrhese,  infection 
is  Dy  far  tneTnostimportant.  This  fact  has  long  been  recognised,  but  it 
is  only  of  late  that  the  bacteria  concerned  have  been  identified,  and  then 
only  in  a  small  proportion  of  the  cases.  In  2  of  the  3  instances  which 
have  come  under  my  observation,  the  infection  was  due  to  the  streptococcus, 
and  in  the  third  to  the  streptococcus  and  colon  bacillus.  Berkley  likewise 
reports  a  case  due  to  the  organism  first  mentioned. 

Auto-intoxication  is  also  a  frequent  serological  factor,  and  it  is  probable 
that  the  vast  majority  of  mental  derangements  following  eclampsia  are  due 
to  this  condition.  Ordinarily,  insanity  is  regarded  as  a  rare  complication 
of  eclampsia,  though  Olshausen  observed  it  in  6  per  cent  of  his  515  cases. 
According  to  Hansen,  infection  and  auto-intoxication  are  responsible  for 
more  than  80  per  cent  of  all  cases,  while  the  remainder  are  to  be  attributed 
to  other  causes,  occurring  particularly  in  women  afflicted  with  hereditary 
tendencies,  the  exciting  cause  of  the  insanity  being  shock,  extreme  mental 
depression,  or  the  rapid  loss  of  a  large  quantity  of  blood. 

The  puerperal  psychosesjare  usually  characterized  by  gre^t  excitement 
during  the  first  few  days,  associated  with  all  sorts  of  hallucinations.  Later 
the  maniacal  symptoms  disappear,  and  the  patient  passes  into  a  condition  of 
depression,  and  frequently  exhibits  suicidal  tendencies. 

The  prognosis  is  most  favourable  in  the  cases  following  eclampsia,  the 
majority  of  these  patients  recovering.  On  the  other  hand,  those  following 
infection  are  very  tedious,  and  20  to  40  per  cent  of  the  women  fail  to  regain 
their  mental  equilibrium.  It  is  not  unusual  for  the  mental  derangement 
to  last  for  from  three  to  six  months,  although  the  prospect  for  recovery  is 
poor  if  the  latter  period  is  exceeded.  It  is  generally  stated  that  from  5  to 
10  per  cent  of  the  patients  afflicted  with  puerperal  insanity  die,  this  high 
mortality  rate  being  due,  of  course,  to  the  underlying  infection  and  not  to 
the  mental  derangement  itself. 

In  cases  following  infection,  the  treatment  should  first  be  directed  to  the 
underlying  condition,  and  the  directions  described  in  Chapter  XLIV  rigor- 
ously followed.  The  acute  maniacal  symptoms  should  be  met  by  the  admin- 
istration of  sedatives,  and  the  patient  should  be  watched  most  carefully 
throughout  her  entire  illness,  more  particularly  during  the  periods  of  de- 
pression, during  which  she  should  never  be  left  alone  for  fear  that  she  may 
do  an  injury  to  herself.  If  prompt  improvement  does  not  follow  the  dis- 
appearance of  the  symptoms  ascribable  to  infection,  the  patient  should  be 
placed  in  charge  of  a  competent  psychiatrist. 


814  OBSTETRICS 

Typhoid  Fever. — This  is  not  an  infrequent  complication  of  the  puer- 
perium.  Its  course,  however,  varies  but  little  from  that  observed  under 
other  conditions,  although  the  prognosis  is  necessarily  somewhat  influenced 
by  the  fact  that  the  patient  is  already  debilitated  by  the  strain  incident  to 
labour.  The  diagnosis  should  never  be  made  unless  a  definite  Widal  reac- 
tion can  be  demonstrated,  inasmuch  as  all  the  other  symptoms  of  the.  dis- 
ease may  be  associated  with  a  prolonged  puerperal  sepsis,  especially  when 
the  endocardium  is  involved.  Furthermore,  the  so-called  typhoid  condi- 
tion is  often  encountered  in  various  forms  of  pysemia. 

Malarial  Fever. — In  certain  districts  the  puerperium  is  not  infrequently 
complicated  by  malarial  infection.  Although  the  course  of  the  disease  is 
not  materially  influenced  by  the  fact  that  the  patient  has  recently  given 
birth  to  a  child,  it  is  interesting  to  note  that  labour,  no  less  than  surgical 
procedures,  seems  to  predispose  to  a  recrudescence  of  the  disorder  in  women 
who  have  already  suffered  from  it,  the  typical  phenomena  of  ten.  appearing 
during  the  first  few  days  of  the  puerperium. 

Too  many  sins  of  omission  and  commission  on  the  part  of  the  obstetri- 
cian have  undoubtedly  been  cloaked  under  the  diagnosis  of  "  malaria."  At 
the  present  day,  whenever  a  patient  presents  a  temperature  characterized 
by  marked  remissions  and  possibly  by  chills,  puerperal  infection  should  be 
suspected,  and  the  existence  of  malarial  fever  should  never  be  seriously 
entertained  unless  all  other  possibilities  have  been  practically  eliminated 
and  the  characteristic  parasites  have  been  found  in  the  blood. 

As  soon  as  a  positive  diagnosis  has  been  made,  quinine  should  be  given 
in  sufficiently  large  doses  to  break  up  the  attack,  as  it  exerts  no  appre- 
ciable influence  upon  the  mammary  secretion  or  the  well-being  of  the 
child. 

Pneumonia. — Croupous  pneumonia  is  a  rare  complication  of  the  puer- 
peral state,  unless  the  disease  has  existed  before  the  onset  of  labour.  The 
outlook  is  always  serious. 

The  lobular  variety,  or  broncho-pneumonia,  is  often  a  terminal  process, 
and  is  one  of  the  most  common  causes  of  death  in  patients  who  succumb 
within  a  few  days  following  an  eclamptic  attack.  The  treatment  does  not 
differ  essentially  from  that  employed  at  other  times. 

Scarlet  Fever. — Although  scarlet  fever  is  rarely  encountered  during  the 
puerperium,  its  occurrence  has  given  rise  to  a  great  deal  of  discussion  and  a 
very  considerable  literature.  The  interest  manifested  in  the  disease  is 
largely  to  be  accounted  for  by  the  fact  that  a  scarlatiniform  rash  is  occa- 
sionally observed  during  the  course  of  a  puerperal  infection,  so  that  in 
many  cases  a  differential  diagnosis  becomes  very  difficult. 

Epidemics  of  scarlet  fever  in  the  puerperium  have  been  reported  by 
Boxall,  Meyer,  Ahlfeld,  and  others.  Nevertheless,  it  would  appear  that 
the  puerperal  woman  is  to  a  certain  extent  immune  from  the  disease,  inas- 
much as  statistics  go  to  show  that  only  a  small  proportion  of  those  exposed 
to  the  contagion  become  infected.  Thus,  Meyer  found  the  rate  of  morbidity 
to  be  about  1  per  cent  among  his  patients. 

It  is  generally  stated  that  infection  may  occur  in  the  usual  manner  as 
well  as  by  the  entrance  of  the  specific  poison  through  wounds  about  the  geni- 


ACUTE   INFECTIOUS  DISEASES  DURING   THE   PUERPERIUM      815 

talia.    The  belief  in  the  possibility  of  the  Latter  eventuality  is  based  upon 

the  lad  that  (he  rash  occasionally  appears  lirsi  in  (he  neighbourhood  of  the 
vulva,  and  thence  spreads  to  other  portions  of  the  body.  Moreover,  the  fre- 
quent association  of  pelvic  inflammatory  t roubles,  and  the  occasional  locali- 
zation of  diphtheritic  patches  in  the  vulva  or  vagina,  instead  of  in  the  throat, 
are  advanced  iu  support  of  the  view.  Modern  bacteriological  investigation. 
however,  has  destroyed  the  force  of  this  last  argument,  since  it  has  shown 
that  the  so-called  diphtheritic  deposits  occurring  in  the  throat  in  scarlet 
fever  are  due  to  a  coincident  streptococcic  infection.  Moreover,  since  such 
conditions  about  the  genitalia  usually  have  a  similar  origin,  it  would  appear 
difficult  to  differentiate  between  those  complicating  scarlet  fever  and  the 
varieties  occurring  during  the  course  of  puerperal  infection.  It  is  also 
urged  that  the  appearance  of  the  disease  on  the  third  or  fourth  day  of  the 
puerperium  speaks  in  favour  of  transmission  of  contagion  through  the 
genitalia. 

In  frank  cases,  the  diagnosis  is  readily  made  from  the  existence  of  a 
characteristic  rash,  which  is  later  followed  by  desquamation.  Moreover,  the 
strawberry  tongue,  the  development  of  pseudo-diphtheritic  patches  in  the 
pharynx,  the  appearance  of  albumin  in  the  urine,  together  with  a  history 
of  exposure  to  possible  contagion,  usually  remove  all  doubt.  On  the  other 
hand,  in  the  absence  of  characteristic  manifestations,  the  diagnosis  cannot 
be  made,  it  being  often  impossible  to  differentiate  between  scarlet  fever 
and  puerperal  infection,  even  when  a  distinct  history  of  exposure  to  conta- 
gion can  be  elicited. 

The  prognosis  is  largely  the  same  as  under  other  circumstances,  mild 
forms,  as  a  rule,  ending  in  recovery,  whereas  patients  affected  with  the 
hemorrhagic  variety  usually  die.  The  puerperium  appears  to  exert  little 
effect  upon  the  course  of  the  disease,  the  death-rate  not  being  higher  than 
under  ordinary  conditions.     The  child  may  or  may  not  be  infected. 

Measles  and  small-pox  occasionally  occur  during  the  puerperium,  but 
their  course  does  not  differ  materially  from  that  observed  in  women  who 
have  not  recently  given  birth  to  children. 

Diphtheria. — True  diphtheritic  patches,  in  which  the  Klebs-Loeffler  ba- 
cillus can  be  demonstrated,  occasionally  occur  upon  denuded  portions  of 
the  vulva  and  vagina.  They  may  be  due  to  a  primary  genital  infection, 
or  be  merely  part  of  a  process  primarily  localized  in  the  throat.  Inasmuch 
as  pseudo-diphtheritic  patches  in  the  genital  tract  during  the  course  of 
puerperal  infection  are  not  of  rare  occurrence,  the  presence  of  a  fibrinous 
exudate  about  the  vagina  or  vulva  should  lead  to  a  diagnosis  of  diphtheria 
only  in  those  cases  in  which  the  characteristic  bacilli  can  be  demonstrated. 
If  the  process  is  limited  to  the  genital  tract,  the  constitutional  symptoms 
are  not  severe,  and  the  disease  usually  pursues  a  benign  course,  readily 
yielding  to  the  employment  of  the  anti-diphtheritic  serum. 


816  OBSTETRICS 


LITERATURE 

Ahlfeld.     Spaltung  der  Anlage  der  Brustdrilse,  Polymastie.    Die  Missbilclung  des  Men- 

schen.     Leipzig,  1880,  110-113. 
Ueber  Exantheme  im  Wochenbette,  etc.     Zeitschr.  f.  Geb.  u.  Gyn.,  1893,  xxv,  31-44. 
Berkley.     The  Insanities  of  the  Puerperal  Period.     A  Treatise  on  Mental  Diseases,  1900, 

307-328. 
Boxall.     Scarlatina  during  Pregnancy  and  in  the  Puerperal  State.     Trans.  Lond.  Obst. 

Soc,  1889,  xxx,  11-77;  126-154. 
Bumm.     Zur  Aetiologie  der  puerperalen  Mastitis.    Archiv  f.  Gyn.,  1886,  xxvii,  460-484. 
Burckhard.     Gangran  der  unteren  Extreraitaten  im  Wochenbette.     Centralbl.  f.  Gyn., 

1900,  1381-1384. 
Carter.     Obstetrical  Paralysis,  etc.     Boston  Med.  and  Surg.  Jour.,  May  4,  1893. 
ChantEiMESSE  et  Widal.     Recherches  sur  l'etiologie  du  tetanus.     Le  Bull.  Med.,  1889, 

No.  74. 
Chiari,  Braun  und  Spaeth.     Acquirirte  Volumsabnahme  des  Uteruskorpers..  Klinikder 

Geb.,  1854,  371-372. 
Deneux.     Memoire  sur  les  tumeurs  sanguines  de  la  vulve  et  du  vagin.     Paris,  1830. 
Doderlein.     Die  Atrophia  uteri.     Veit's  Handbuch  der  Gyn.,  1897,  ii,  391-402. 
Duchenne.     Paralysies  obstetricales  infantiles  du  membre  superieur.     De  l'electrisation 

localisee.     Paris,  1872,  3me  ed.,  357. 
Fieux.     De  la  pathogenie  des  paralysies  brachiales  chez  le  nouveau-ne.    Annales  de  Gyn. 

et  d'Obst.,  1897,  xlvii,  52-64. 
Goldberger.     Ein  seltener  Fall  von  Polymastie.     Archiv  1  Gyn.,  1895,  xlix,  272-277. 
Gottschalk.     Beitrag  zur  Lehre  von  der  Atrophia  uteri.     Volkmann's  Sammlung  klin. 

Vortrage,  N.  P.,  Nr.  49. 
Hansen.     Ueber  das  Verhaltniss  zwischen  der  puerperalen  Geisteskrankheit  u.  der  puer- 
peralen Infection.     Zeitschr.  f.  Geb.  u.  Gyn.,  1888,  xv,  60-127. 
Heyse.     Ueber  Tetanus  puerperalis.     Deutsche  med.  Wochenschr.,  1893,  Nr.  14,  318. 
Honigmann.     Bakteriologische  Untersuchungen  iiber  Frauenmilch.     D.  I.,  Breslau,  1893. 
Hunermann.     Ueber  Nervenlahmung  im   Gebiete  des  Nervus   ischiadicus   infolge   von 

Entbindungen.     Archiv  f.  Gyn.,  1900,  xlii,  489-512. 
Jacquet.     Ueber  Atrophia  uteri.     Berliner  Beitrage  zur  Geb.  u.  Gyn.,  1873,  ii,  1-11. 
Kentmann.     Tetanus  puerperalis.     Monatsschr.  f.  Geb.  u.  Gyn.,  1900,  xi,  527-539. 
Kostlin.     Beitrage  zur  Frage  des  Keimgehaltes  der  Frauenmilch  u.  zur  Aetiologie  der 

Mastitis.     Archiv  f.  Gyn.,  1897,  liii,  201-277. 
Lafond.     De  la  gangrene  des  membres  inferieurs  dans  les  suites  de  couches.     These  de 

Bordeaux,  1901. 
Laurent.     Gynakomastie,  etc.     Bibliothek  fur  Socialwissenschaft.     Leipzig,  1896,  vi. 
Meyer.    Ueber  Scharlach  bei  Wochnerinnen.    Zeitschr.  f.  Geb.  u.  Gyn.,  1888,  xiv,  289-351. 
Neugebauer.     Eine  bisher  einzig  dastehende  Beobachtung  von  Polymastie  mit  10  Brust- 

warzen.     Centralbl.  f.  Gyn.,  1886,  729-736. 
Olshausen.     Beitrag  zu  den  puerperalen   Psychosen.  speciell  den  nach  Eklamprie  auf- 

tretenden.     Zeitschr.  f.  Geb.  u.  Gyn.,  1891,  xxi,  371-385. 
Rubeska.     Beitrage  zum  Tetanus  puerperalis.     Archiv  f.  Gyn.,  1897,  liv,  1-12. 

Zur  Behandlung  von  wunden  Warzen  und  Mastitiden  im  Wochenbett.     Archiv  f.  Gyn., 

1899,  lviii,  177-184. 
Sarfert.     Diplokokken  im  Eiter  bei  Mastitis.     Deutsche  med.  Wochenschr.,  1894,  Nr.  8. 
Schoemaker.     Ueber  die  Aetiologie  der  Entbindungslahmungen,  etc.     Zeitschr.  f.  Geb.  u. 

Gyn.,  1899,  xli,  33-53. 
Stolper.     Ueber  Entbindungslahmungen.     Monatsschr.  f.  Geb.  u.  Gyn.,  1901,  xiv,  49-65. 
Thomas.     Obstetrical  Paralysis,  Infantile  and  Maternal.     The  Johns  Hopkins  Hospital 

Bulletin,  1900,  xi,  279. 


DISEASES   AND   ABNORMALITIES  OF  THE    PUERPERIUM         817 

Thorn.     Beitragzur  Lebre  von  der  Atrophia  uteri.    Zeitschr.  f .  Geb.  u.  Gyn.,  1889,  xvi, 

57-105. 
Vinay.     l>u  tetanus  puerperal.     Archives  ele  Tocologie,  1892,  six,  179. 
Vineberg.     A  Further  Contribution  to  the  Study  and  Practical  Significance  of  Lactation 

Atrophy  of  the  Uterus.     Amer.  Gyn.,  11)02,  i,  No.  2. 
Winckel.    Entzlindung  des  Brustdriisenparenchytns,  etc.    Die  Pathologie  u.  Therapie 

des  Wochenbetts.     III.  Aufl.,  1878,  428-439. 
Winscheid.     Neuritis  gravidarum  and  Neuritis  puerperalis.     Oracle's  Saramlung  zwang- 

loser  Abhandlungen  auf  dem   Oebiete   der  Fniuenheilkunde   und   Oeb.,   1898,  iii, 

Heft  8. 
Wok.mser.     Nochmals  zur  puerperalen  Gangran  der  unteren  Extremitiiten.     Centralbl.  1'. 

Gyn.,  1901,  110-113. 


53 


INDEX 


Abdomen,    discoloration    of,    in    pregnancy, 
154. 
enlargement  of,  during  pregnancy,  1<n. 
foetal,  enlarged,  cause  of  dystocia,  684. 
pendulous,   172,  572,  GIG. 
stria?  "f.  in  pregnancy,  151. 
Abdominal  binder,  309. 
pedicle,  97. 
pregnancy,  ."42.  ."44. 
wall,  changes  in,  during  puerperium,  304. 

emphysema  of,  742. 

function  of,  during  labour,  219. 
Abortion,  521. 
aetiology  of,  521. 
changes  in  foetus  in,  526. 
clinical  history  of,  527. 
complete,  527. 
criminal,  521. 
curettage  in,  429,  529. 
ergot  in,  529. 
exciting  causes  of,  523. 
frequency  of,  521. 
in  cholera,  436. 

in  retroflexed  pregnant  uterus,  473. 
in   typhoid  fever,   437. 
incomplete,  527. 
induction  of,  for  contracted  pelves,  340. 

for  diseases  of  ovum,  339. 

for  infection  of  uterine  contents,  339. 

for  malignant  growths,  340. 

for  ovarian  tumours,  340. 

for    pernicious    vomiting    of    pregnancy, 
462. 

for  renal  insufficiency,  339. 

for  retroflexed  pregnant  uterus,  339. 

for  uterine  haemorrhage,  339. 

for  uterine  myomata,  340. 

for  vomiting  of  pregnancy,  339. 

methods  of.  340. 
membranes,  retention  of,  in,  530. 
miscarriage,  521. 
missed,  530. 

mole,  formation  of,  in.  525. 
neglected,  530. 
pathology  of,   524. 
predisposing  causes  of,  523. 
prophylaxis  of,   527. 
repeated,  524. 
rupture  of  uterus  in,  530. 
threatened.  527. 
treatment  of,  528. 
tubal,  540. 
vaginal  tampon  in,  431. 


Absces  de  fixation,  791. 
Abscess,  in  puerperal  fever,  769. 

of  Bartholin's  gland,  27,  467. 

of  breast,   810. 

pelvic,  707. 

retro-mammary,  811. 
Absolute    indication    for    Caesarean    section, 

402. 
Acanthopelys,  G7G. 
Acardiacus,  681. 
Accessory  fontanelle,   13G. 
Accessory  ostium  of  tube,  54. 
Accidental  haemorrhage,  715. 
Accidents  during  pregnancy,  450. 
Accommodation  theory  as  to  production  of 

presentations,  186. 
Accouchement  force,  347. 

for  haemorrhage  due  to  premature  separa- 
tion of  placenta,  716. 

in  eclampsia,  708. 

in  placenta  praevia,   724. 

versus  post-mortem  Caesarean  section,  410. 
Acephalicus,  681. 

Acetonuria  during  puerperium,  308. 
Achondroplasia,   609,   641. 
Acormus,  681. 

Acromio-iliac     presentations.       (See     Trans- 
verse Presentations.) 
Acute     infectious     diseases    in    pregnancy, 
344. 

oedema  of  cervix,  477. 
Adhesions,  amniotic,  498. 
Adipocere,   545. 
After-coming  head,   forceps  to,  378,  388. 

in  contracted  pelves,  621. 

perforation  of,  420,  683. 
After-pains,  306,  310. 
Agalacia,  809. 

Age  of  foetus,  calculation  of.  131. 
Air,  entrance  of,  into  veins.  023.  760. 

entrance  of,  into  uterine  sinuses,  755. 

infection,    771. 
Albuginea.   57. 

Albuminometer,  Esbach's,  458. 
Albuminuria,  changes  in  placenta  in,  505. 

during  pregnancy.   154,  455. 

during  puerperium,  307. 

in  eclampsia,  698. 

relation   to   premature   separation   of   pla- 
centa, 714. 
Albuminuric   retinitis.    696. 
Alimentation,   rectal,   in  hyperemesis,  402. 
Allantoic  vesicle,  95. 

819 


820 


OBSTETRICS 


Allantois,  95,  123. 
Amaurosis  during  pregnancy,  448. 
Arnenorrhoea,   conception  during,  165. 
Amnion,  92,  117,  121,  122. 

adhesions  of,  498. 

cysts  of,  499. 

dermoids  of,  499. 

diseases  of,  493. 

dropsy  of,  493. 

fluid  of,  104. 

formation  of,  in  chickens,  93. 
in  mammals,  93. 
in  man,   95. 
in  monkeys,  98,  100. 

inflammation  of,  499. 

structure  of,  104. 
Amniotic  adhesions,  498. 
Amniotic  fluid,  functions  of,  142. 

origin   of,    141,    494,   498. 
Amorphus,  681. 
Ampulla  of  tube,  51. 
Ampullar  pregnancy,  539. 
Amputation,  intra-uterine,  499. 

of  leg,  effect  upon  pelvis,  674. 
Anaemia,  pernicious,  344. 
Anaerobic   bacteria   in    puerperal   infection, 

760,  762. 
Anaesthesia,  291. 

cocaine,  293. 

in  heart  disease,  442. 

in  irregular  pains  of  first  stage,  566. 

in  normal  labour,  291. 

in  painful  labour,  566. 

in  precipitate  labour,  567. 

post-partum,   805. 
Anencephalus,  681. 
Annular  detachment  of  cervix,  736. 
Anteflexion,  in  contracted  pelves,  616. 

of  pregnant  uterus,  472. 

of  puerperal  uterus,  804. 
Antepartum  eclampsia,  695. 

haemorrhage,  713,  717. 
Anteversion  of  pregnant  uterus,  472. 
Anthrax  during  pregnancy,  438. 
Antistreptococcic  serum,  790. 
Antitetanus  serum,  797. 
Anus,  laceration  of  sphincter  of,  296. 

lesions  of,  during  labour,  225. 
Apoplexy  during  pregnancy,  448. 

in  eclampsia,   701. 

of  placenta,  503. 
Appendicitis  during  pregnancy,  451. 
Apron,  Hottentot,  25. 
Arbor  vitae  uterina,  37. 
Area,   embryonic,  88. 

germinativa,  88. 

opaca,  89. 

pellucida,  89. 
Areola,  glands  of  Montgomery  in,  152. 

of  pregnancy,  152. 

secondary,  152. 
Arteries.     (See  Blood-vessels.) 
Artificial  feeding,  323. 

respiration.    (See  Asphyxia  Neonatorum.) 
Ascites,  of  foetus,  obstructing  labour,  683. 

simulating  pregnancy,  168. 


Asphyxia,  from  rupture  of  vasa  praevia,  509. 

intra-uterine,    749. 

livida,  750. 

neonatorum,   751. 

pallida,  750. 

resuscitation  from,  751. 

trepanation  for,  753. 
Assimilation  pelvis,  651. 
Asthma  during  pregnancy,  443. 
Astringents     in     post-partum     haemorrhage, 

729. 
Atony  of  uterus,  726. 
Atresia  of  cervix,  571. 

of  vagina,    569. 

of  vulva,  569. 
Attitude  of  foetus,  180. 
Auscultation,  obstetrical,  15S,  190. 

errors  in,   191. 

foetal  heart,  158. 

foetal  heart  murmurs,  159. 

funic  souffle,  159. 

gas  in  maternal  intestines,  160. 

in  multiple  pregnancy,  332. 

movements  of  foetal  diaphragm,  160. 

placental  souffle,  159. 

uterine  souffle,  159. 
Auto-infection,  772. 
Auto-intoxication  of  pregnancy,  455. 

relation  of,  to  eclampsia,  703. 
to  insanity,  813. 

simulating  puerperal  infection,  781. 
Axis  of  pelvis,  10. 
Axis  traction  forceps,  375. 

Bacillus  aerogenes  eapsulatus,  cause  of  em- 
physema of  abdominal  walls,  742. 

infection    with,    cause   of   fcetal   dystocia, 
685. 

infection    with,    simulating   air   embolism, 
755. 

in  puerperal  infection,  759. 
Bacillus  coli  communis,   in  puerperal  infec- 
tion,   759. 

in  tympanites  uteri,  759. 
Bacillus  diphtheria?   in   puerperal   infection, 

759. 
Bacillus    typhosus    in    puerperal    infection, 

760. 
Bacterial  origin  of  eclampsia,  703. 
Bacteriology  of  lochia,  306,  783. 

of  puerperal  infection,  757. 

of  vaginal  secretion,   773. 
Bag  of  waters,  104,  142,  200.  217.  283. 
Ballottement,   160. 

Bandl's  ring.     (See  Contraction  Ring.) 
Barnes's  fiddle-bag,  346. 
Bartholin's  glands,  27. 

inflammation  of,  during  pregnancy,  467. 
Basal  plate  of  decidua,  116. 
Basilyst,  422. 
Basiotribe,  421. 
Bath.  cold,  in  puerperal  fever,  789. 

during  labour,  278. 

of  new-born  child,  315. 

sweat,  in  eclampsia,  707. 
Battledore    placenta,    508. 


IXDKX 


821 


Baucbstiel,  'J7. 

Baudelocque's  cephalotribe,  421. 

diameter,  5mj. 

pelvimeter,  584. 
Bichloride   of    mercury,    Intravenous    injec- 
tion of,  in  puerperal  i>\  er,  791. 
Bichloride     poisoning     from     Intra-uterlne 

douche,  429,  7s7. 
Bicornuate  uterus,  cause  of  dystocia,  471. 

hernia  of,    178. 

pregnancy  in,  471. 

rupture  of,  471. 
Binder,  use  <>!'.  (luring  puerperium,  309. 
Bipolar  version,  393,  397,  723. 
Bladder,  changes  in.  during  pregnancy.  154. 

ectopia  of,  649. 

gangrene  of,  474. 

rupture  of.   47.">. 

tumour  of.  complicating  labour,  578. 
Blastodermic  vesicle.  87. 
Blecard's  sign  of  maturity  of  foetus,  132. 
Bleeding  in  eclampsia,  709. 
Blood,  alkalinity  of,  in  pregnancy.  153. 

changes  in,  during  pregnancy,  153. 
during  puerperium,  300. 

freezing  point  of,  139. 

moles,  525. 

serum,  toxcity  of.  in  eclampsia,  703. 
Blood-vessels  of  clitoris,  26. 

of  ovaries.  46. 

of  placenta.  119. 

of  uterus,   45. 

of   vagina,  34. 

pudic,  222. 

umbilical.  119,  123,  137,  508. 

vestibular  bulbs,  27. 
P. lot's  perforator.  419. 
Blunt  hook.  391. 
Bougie,   for  induction  of  premature  labour, 

34.}. 
Bowels  in  pregnancy,  176. 
Brachycardia  during  puerperium,  305. 
Brain,  changes  in.  in  eclampsia,  701. 
Braun's   blunt   hook,   424. 

eranioclast.  421. 

trepan.  419. 
Braxton  Hieks's  method  of  version,  393,  397. 

sign  of  pregnancy.  164. 
Breasts,  absence  of.  807. 

anatomy  of,  318. 

areola  of.  152. 

caked.  809. 

care  of.  during  nursing,  323. 
in  pregnancy.  177. 

changes  in.  during  pregnancy,  152,  155. 

engorgement  of,  809. 

hypertrophy  of.  .807. 

inflammation  of.   810. 

supernumerary.  807. 
Breech  presentations,  182,  250. 

asphyxia  in.  261. 

blunt  hook  in.  391. 

bringing  down  foot  in  frank.  262.  390. 

causation  of.  258. 

cephalic  version  in,  392. 

complicated  by  contracted  pelves,  633. 


Breech  presentations,  diagnosis  of,  257. 

extraction   of,   261,   381. 

ftllel  In,  391. 

forceps  in.  ;;vs.  :;:n. 

frequency  of,  257. 

in  hydrocephalus,  082. 

liberation  of  arms  in,  718. 

mechanism  of,  258. 

prognosis  in,  260. 

prolapse  of  cord  in,  747. 

treatment  of,  during  labour,  201. 
during  pregnancy,  261. 
Bright  "s  disease.     (See  Nephritis.) 
Brim  of  pelvis.    (See  Pelvis.) 
Broad  ligament.  43. 

pregnancy,  543. 
Broncho-pneumonia   in   puerperal   infection, 

780. 
Brow  presentations,  181,  253. 

causation  of,  254. 

configuration  of  head  in,  255. 

conversion  of.  into  face  or  vertex,  256. 

frequency  of,  254. 

mechanism  of,  254. 

prognosis  in,  255. 

symphyseotomy  in,  257. 

treatment  of.   255. 

version   in,   256. 
Bruit,  uterine,  159. 
Budin's  pelvimeter,  584. 
Byrd's  method  of  resuscitation,  752. 

Csesarean  section,  checking  haemorrhage  in, 
405. 
conservative,  401. 
contra-indications  for,  403. 
extraperitoneal,  410. 
following  vagino-fixation,  573. 

ventro-fixation.  572. 
for  carcinoma  of  cervix,  468. 

of  rectum,  579. 
for  contracted  pelves,  62S,  632,  636. 
for  myoma  of  uterus,  575. 
for  old  extra-uterine  pregnancy,  552. 
for  ovarian  tumour.  577. 
for  placenta  praevia.  724. 
history  of,  400. 
hysterectomy  after,  406. 
indications  for,  402. 
in  eclampsia,  708. 
instead  of  induction  of  premature  labour, 

in  transverse  presentations.  691. 

Porro's  operation,  406. 

post-mortem,  410. 

prognosis  of,  408. 

repeated.  409. 

sterilizing  patients  after,  407. 

technique  of,  403. 

vaginal,  409. 
Calcification  of  foetus.  545,  688. 

of  placenta.  507. 
Callus  formation,   effect  upon  pelvis.   676. 
Canal,    cervical,   37,   208,  215. 

of  Nuek,  25. 
Canalized  fibrin,  116.  118.  122.  504. 


822 


OBSTETRICS 


Cancer.    (See  Carcinoma.) 
Caput  succedaneum,  189,  243,  622. 
Carbamic  acid,  relation  to  eclampsia,  703. 
Carbolic-acid    poisoning    from    intra-uterine 

douche,  429. 
Carbon  dioxide,  increase  of,  in  blood,  cause 

of  labour,  194. 
Carcinoma  of  cervix,   Csesarean  section  for, 
403,  468. 

complicating  pregnancy,  340,  468. 

of  rectum,  cause  of  dystocia,  403. 
Carcinoma  syncytiale,  490. 
Cardiac  lesions  in  pregnancy,  343. 
Carneous  moles,  525. 
Carunculse  myrtiformes,  30,  169,   304. 
Catheterization  during  puerperiuni,  311. 
Caul,  217. 

Causation  of  labour,  193. 
Cell  layer  of  chorion,  102. 

mass,  internal,  88. 

nodes,  114,  115. 
Cellulitis  in  puerperal  infection,  789. 
Central  placenta  prsevia,  717. 
Cephalalgia,   during  pregnancy,  447. 

in  threatened  eclampsia,  694. 
Cephalic  version,  392. 

indications  for,  392. 

methods  of,  393. 
Cephalotribe,  421. 
Cervical  ganglion,  49,  146. 
Cervico-vesical  fistula,  745. 
Cervix,  36. 

acute  oedema  of,  477. 

anatomy  of,  36. 

annular  detachment  of,  736. 

apparent  shortening  of,  in  pregnancy,  208. 

arbor  vitse  uterina,  37. 

atresia  of,  571. 

carcinoma  of,  340,  468. 

changes  in,  during  labour,  198. 
during  pregnancy,  164. 

circular  detachment  of,  736. 

condition  of,  in  latter  part  of  pregnancy, 
208. 

dilatation  of.   during  labour,  215. 
manual,  348. 
with  forceps,  357,  379. 

diseases  of,  during  pregnancy,  468. 

external  os,  37. 

ganglion  of,  49. 

glands  of,  38. 

hypertrophy  of  supravaginal  portion   dur- 
ing pregnancy,  168,   477,   572. 

incision  of,   349. 

infravaginal  portion  of,  36. 

in  normal  labour,  209,  211. 

internal  os,   36. 

lesions  of,  during  labour,  736. 

mucosa  of,  37. 

myoma  of,  574. 

rigidity  of.   563,  571. 

stenosis  of,  571. 

stricture  of,  571. 

supravaginal  portion,  36. 

tears,  of,  736. 

vaginal   portion,   36. 


i    Chadwick's  sign  of  pregnancy,  166. 
Chamberlen  forceps,  352. 
Champetier  de  Ribes's  balloon,  346. 
Changes  in  uterus  during  contractions,  198. 
Child.    (See  New-born  Child.) 
Chill,  during  puerperiuni,  304. 

following  normal  labour,  304. 

iu   puerperal  infection,   777. 
Chloroform  in  labour,  292. 
Cholera  complicating  pregnancy,  436. 
Chondrodystrophia  fcetalis,  609,  641. 
Chondrodystrophic  dwarf  pelvis,  641. 
Chorea,  344. 

during  pregnancy,  447. 
Chorio-epithelioma,  490. 
Chorion,   92. 

abortion  from  disease  of,  522. 

canalized  fibrin  of,  116,  118. 

cell  layer  of,  102. 

cystic  degeneration  of,   485. 

decidual  islands  of,  100,  116. 

diffuse  myxoma  of,  493. 

diseases  of,  485. 

epithelioma  of,  489. 

epithelium  of,  99,  102,  115. 

fastening  villi  of,  101,  114. 

formation  of,  in  chickens,  93. 
in  man,  95. 

frondosum,   101,   115. 

giant  cells  of,  102,  116. 

laeve,  101,  115. 

Langhans's  layer  of,  102,  115,  117,  122. 

membrane  of,  99. 

myxoma  fibrosum  of,  493. 

myxoma  of,  486. 

Plasmodium  of,  102. 

stroma   of,    99,    100. 

structure  of,  98,  114,  115,  117,  122. 

syncytium  of,  102,  115,  117. 

trophoblast  of,   95,   113. 

villi  of,  95,  101,  114,  115,  117,  122. 

Zellschicht  of,  102. 
Chorionic  villi.     (See  Villi,   Chorionic.) 

membrane,  99. 

epithelium,  99.   102,  115. 

epithelioma,  489. 
Cilia  of  ovaries,  61. 

of  tubes,  53. 

of  uterus,  40. 
Circular  sinus  of  placenta,  122. 

detachment  of  cervix,  736. 
Circulation  in  foetus,  137. 

in  new-born  child.  314. 
Circumcision,   girl,  26. 
Circumvallate  placenta,  503. 
Cleidotomy,    425. 
Clitoridectomy,  26. 
Clitoris,  26. 

amputation  of,   26. 

anatomy  of,  26. 

prepuce  of,   25. 
Cloasma,  154,  450. 
Closing  plate  of  decidua,  116. 
Clothing  during  pregnancy,  176. 
Club-foot,  effect  upon  pelvis,  675. 
Cocaine  anaesthesia  in  labour,  293. 


iNi)i:x 


>-s. 


Coccyx.  2. 

Coelome,  91. 

Coffin  birth,  755. 

Cohn's  method  of  Inducing  labour,  347. 

Colling  of  cord,  510,  123. 

Coitus  during  pregnancy,  176. 

Collapse  during  labour,  753. 

Colles's  law.  441,  511. 

Collision  of  twins,  334. 

Colostrum,  l-">4.  319. 

corpuscles,  319. 
Colpaporrhexis,  735. 
Colpeurynter    in     induction    of    premature 

labour,  345. 
Colpo-hyperplasia  cystica,  467. 
Columns   of  vagina,   32. 
Combined  pregnancy,  551. 
Complete  abortion,  527. 
Compound  presentation,  691. 
Concealed  hemorrhage,  715,  727. 
Conception,  date  of,  81,  171. 

during  amenorrhoea.  165. 
Conduct  of  normal  labour,  275. 
Confinement,  estimation  of  date  of,  171. 
Congenital  cystic  kidneys,  684. 
Conglomerate  glandular  body,  71. 
Conglutinatio  orificii  externi,  571. 
Conjugata   diagonalis,   6. 

externa,  5S6. 

vera.  5. 
Conjugate,  anatomical,  6. 

Baudelocque's,  5S6. 

diagonal.  6.  590. 

external,  586. 

Meyer's,  9. 

normal,  9. 

oblique,  6,  590. 

obstetrical,  6. 

of  outlet,  593. 

true,  5,  592. 
Conservative  Cesarean  section,  403. 
Constipation  during  pregnancy,  176,  444. 

during  puerperium,  311. 
Constrictor  vaginae,  33,  222. 
Contracted  pelves,  Cesarean  section  in,  402. 

cause  of  difficult  labour,  684. 

classification  of,  594. 

congenital,  600,  609. 

course  of  labour  in,  622. 

craniotomy  in.   418. 

diagnosis  of.  583. 

due    to    abnormal    malleability    of    bones, 
598. 
to  bilateral  lameness,  674. 
to  diseases  of  the  vertebral  column,  654. 
to    generalized    and    symmetrical    anom- 
alies in  development.  638. 
to    localized    and    asymmetrical    anoma- 
lies in  development,  642. 
to    localized    and    symmetrical    anoma- 
lies in  development.  648. 
to  tumours,  etc..  676. 
to  unilateral  lameness,  672. 

effect  of,  upon  course  of  pregnancy,  616. 

frequency  of,  581. 

history  of,  580. 
K 


Contracted    pelvis,    in    new-born    child,    600, 
609. 
Induction  of  abortion  in,  340. 
of  premature  labour  for,  341. 
mechanism  of  labour  in,  618. 
pelvimetry  in,  584. 
prognosis  of  labour  In,  626. 
size  of  foetus   in,   U17. 
treatment  of  labour  complicated  by,  628. 
X   rays  in  diagnosis  of,  5'.i4. 
Contraction,  centre  for  uterine,  195. 
hour-glass  of  uterus,  568. 
painless,   164. 
uterine.  164,  200,  218. 
ring,   211. 
cause  of  dystocia,  567. 
in   dystocia,    due   to    contracted    pelves, 

622. 
in  threatened  rupture  of  uterus,  739. 
Conversion  in  brow  presentations,  256. 

in  face  presentations,  253. 
Convulsions.    (See  Eclampsia.) 
Cord,     (hee  Umbilical  Cord.) 
Cornua  of  uterus,  35,  469. 
Corona  radiata,  65. 
Coronal  suture,  135. 
Corpulence  simulating  pregnancy,  168. 
Corpus  albicans,  68. 
fibrosum,  68. 
luteum,  66,  150. 
cystic,   71. 

evidence  of  pregnancy,  71. 
false,  71. 

of  menstruation.  71. 
of  pregnancy,   71. 
structure  of,   67. 
true,  71. 
Corrosive    sublimate.      (See    Bichloride    of 

Mercury.) 
Cortex  of  ovary,  57. 
Cotyledons  of  placenta,  121. 
Coxalgia,  672. 
Cranioclast,  421. 
Craniopagus,  680. 
Craniotomy,  418. 
dangers  of,   402. 

for  old  extra-uterine  pregnancy,  552. 
in  collision  of  twins,  334. 
in  contracted  pelves,  628,  631,  632. 
in  face  presentations,  chin  posterior,  253. 
in  hydrocephalus,  683. 
in  rupture  of  uterus,  743. 
indications  for.   418. 
prognosis  of.  423. 
recovery  from,   423. 
technique  of,  419. 
upon  aftercoming  head,  420. 
Cranium.     (See  Head,   Fetal.) 
Cravings  in  pregnancy.  134,  166. 
Crede's  method  of  expressing  placenta,  270. 
Cretin  dwarf  pelvis.  642. 
Criminal  abortion,   339. 
Crotchets,  352. 
Culbute,  185. 
Cul-de-sac  of  Douglas.  32. 
Cumulus  oophorus,  64. 


824 


OBSTETRICS 


Curettage,  429. 

dangers  of,   430. 

in  abortion,  529. 

indications  for,  429. 

in  puerperal  infection,  786. 
Cystic  degeneration  of  chorion,  485. 
Cystitis,  during  pregnancy,  447. 

during  puerperium,  799. 
Cystocele,  complicating  labour,  578. 
Cysts  of  umbilical  cord,  511. 

of  corpus  luteum,  71. 

of"  ovary,   complicating  diagnosis  of  preg- 
nancy, 168. 

of  placenta,  505. 

of  vaginal  walls  obstructing  labour,  571. 

Death  of  foetus  during  pregnancy,  169. 

of  mother  during  labour,  753. 
during  pregnancy,  410. 
Decapitation,  424. 

in  locked  twins,  334. 

in  transverse  presentations,  691. 
Decidua,  95,  105. 

bacteria  in,  481. 

basal  plate  of,  116. 

basalis,  106. 

capsularis,  106. 

cells  of,  106. 

cervical,  105,  720. 

changes  in,  in  abortion,  524. 

closing  plate  of,  116. 

compact  layer  of,  106,  107. 

development  of,  outside  of  uterus,  109. 

diffuse  thickening  of,  480. 

diseases  of,  479. 

fatty  degeneration  of,  194. 

giant  cells  of,  112. 

glandular  hyperplasia  of,  480. 
layer  of,  106. 

gonococci  in,  482. 

hyperplasia  of,  480. 

in  bicornuate  uterus,  470. 

in  extra-uterine  pregnancy,  546. 

in  non-pregnant  tube  in  intra-uterine  preg- 
nancy, 546. 

in  ovaries,  109. 

in  peritonaeum,  109. 

inflammation  of,  481. 

islands  of,  116. 

menstrual.   77. 

origin  of,  109. 

polyposa,  480. 

pseudo-reflexa,   547. 

reflexa,  106,  109,  113. 

reparation  of,  in  puerperium,  302. 

serotina,  106,   112. 

spongy  layer  of,  106,  108. 

syphilis  of,  516. 

tuberous  subchorial  hsematoma  of,  525. 

vera,  106. 
Decidual  cast  in  extra-uterine  pregnancy,  552. 

cells,  106. 

endometritis.     (See  Endometritis.) 

islands,  100,  116. 

reaction  in  tubes,  535,  546. 

sarcoma,  490. 


Deciduoma  malignum,  407,  489.- 

in  extra-uterine  pregnancy,  549. 

pathology  of,  491. 

treatment  of,  493. 
Deformed  pelves.     (See  Contracted  Pelves.) 
Delivery,   normal,  284. 

post-mortem,  775. 
Dental  caries  during  pregnancy,  463. 
Dermatitis  herpetiformis,  449. 
Dermoid  cysts  of  ovary,  576. 
Descent  of  foetus,  causes  of,  219. 

in  breech  presentations,  258. 

in  brow  presentations,  255. 

in  face  presentations,  250. 

in  vertex  presentations,  231. 
Deutoplasm,  66. 
Development  of  allantois,  95. 

of  amnion,  95. 

of  chorion,  95. 

of  clitoris,  26. 

of  cord,   123. 

of  foetus,  128. 

of  hymen,  29. 

of  ovaries,  59. 

of  ovum,  87. 

of  pelvis,  16. 

of  placenta,  113. 

of  tubes,  49. 

of  uterus,  49. 

of  vagina,  34. 

of  vulva,  25. 
Diabetes  during  pregnancy,  344,  445. 

during  puerperium,  308. 

phloridzin,   142. 
Diagnosis,    differential,    of   pregnancy.    (See 
Pregnancy.) 

of  life  or  death  of  foetus,  169. 

of  pregnancy.    (See  Pregnancy.) 

of  sex  during  pregnancy,  159. 
Diameters  of  head,  136. 

of  pelvis.  4. 
Diastasis  of  recti  muscles  in  pregnancy,  152, 
478. 

in  puerperium,  304. 
Dicephalus,  680. 
Diet  during  pregnancy.  176. 

during  puerperium,  310. 
Differential  diagnosis  of  pregnancy,  167. 
Dilatation  of  cervix,  artificial,  345,  348. 

in  normal  labour,  208,  215. 
Dipagus,  680. 
Diphtheria,  during  puerperium,  815. 

puerperal,  763. 
Diphtheritic  ulcer  of  vulva,  763. 
Diprosopus.  680. 
Discus  proligerus.  64.  65. 
Diseases  complicating  pregnancy,  435. 

complicating   puerperium,    797. 
Disinfection  of  hands.  278. 

of  vulva,  280. 
Displacements.    (See  Uterus.) 
Distinction    between    first    and    subsequent 

pregnancies,  169. 
Diverticula  from  tubes,  54. 
Dolicho-cephalic  head,  cause  of  face  presen- ' 
tation,  248. 


INDEX 


S25 


Dollcho-kyrro-plaly-spondylus,  <'<<'•*'<. 
Doremus's  ureometer,    r>:>. 
Double  Naegele  pelvis,  648. 

uterus,  469. 
1  louche,  iiii  ra-uterlne,  427. 

prophylactic,   127. 

vaginal,  427. 

I  lOUglas'S  '  iil-di  -sue,  32, 

perforation  of,  745. 
Dropsy  of  amnion.    (See  Hydramnios.) 
Dry  labour,  201. 
Duchenne's  paralysis,  S06. 
Dncts,   lactiferous,  318. 
Mullerian,  49. 
Skein's.    27. 
WolflBan,  27.  49. 
Ductus  arteriosus,  138. 

venosus,  138. 
Diihrssen's  cervical  im-isions,  349. 
Duncan's    mechanism   iu   extrusion    of   pla- 
centa, 266. 
Duration  of  pregnancy.  170. 
Duverney's  glands.  27. 
Dwarf.  041. 

pelvis.  641. 
Dyspnoea  during  pregnancy.  444. 
Dystocia  due  to  abnormalities  of  cervix,  571. 
due    to    abnormalities    of    the    expulsive 
forces.  362. 
to  abnormalities  of  vagina.  569. 
to  abnormalities  of  vulva,  569. 
to  contracted  pelves.  598. 
to  contraction  of  Bandl's  ring,  567. 
to  levator  ani  muscle,  571. 
to  old  extra-uterine  pregnancy,  552. 
to  tumours  of  birth  canal,  574. 
to  uterine  displacements,  572. 
following  vaginofixation.   573. 
following  ventrofixation.  572. 
Dysuria  from  incarcerated  pregnant  uterus, 
474. 

Echinococcus  cysts  complicating  labour,  578. 
Eclampsia,  accouchement  force  in,  348,  708. 

aetiology  of.  702. 

albuminuria  in.  698. 

bacterial  origin  of.  703. 

bleeding  in.  709. 

blindness  accompanying.  696. 

Caesarean  section  in.  403,  708. 

clinical  history  of,  693. 

frequency  of.  693. 

in  extra-uterine  pregnancy,  697. 

in  new-born  child.  705. 

mania  following.  696,  813. 

pathology  of.  699. 

prognosis  of.   705. 

treatment  of.  706. 

urine  in,  697. 

venesection  in,  709. 
Ectoderm.  89. 
Ectopic     pregnancy.       (See     Extra  -  uterine 

Pregnancy.) 
Ectropion,  congenital,  39. 
Egg  nests,  59. 
Elastic  ligatures  in  Caesarean  section,  405. 


Elderly  primiparae,  I'm;. 
Electricity  In  extra-uterine  pregnancy,  564. 
Elephantiasis  congenita  cystica,  684. 
Embolism,  air,  760. 

dining  pregnancy,  44:;. 

pulmonary,  during  labour,  755. 
Embryo,  128. 

anatomy  of,  128. 

development  of,  87. 

nourishment  of,  137. 
Embryonic  area,  B8. 

shield,  89. 
Embryotomy,  423. 
Emesis  in  pregnancy,  165,  460. 
Emphysema  complicating  pregnancy.  443. 

foetal,  causing  dystocia,  685. 

of   abdominal    walls   following   rupture   of 
uterus,  742. 
Encephalocele,  499. 
Endarteritis,     compensatory,     during     puer- 

perium,  303. 
Endocarditis  during  pregnancy,  443. 

gonorrhoeae  438,  759. 
Endocervicitis.  468. 
Endometritis,  acute  decidual.  481. 

atrophic  decidual,  481. 

cause  of  abortion,  523. 

cause  of  placenta  praevia,  719. 

cause  of  premature  separation  of  placenta, 
713. 

cervical.  438,  468. 

decidua  cystica,  481. 
glandularis,  480. 

diphtheritic.  763. 

in  pregnancy.  479. 

post-abortum.  801. 

post-partum,  801. 

puerperal,  763. 

putrid,  765. 

septic,  766. 

treatment  of,  482. 
Endometrium,  39. 

in  old  age,  42. 

in  young  child.  42. 

regeneration  of,  after  curettage,  39. 
during  puerperium,  302. 

reticulum  of,  43. 

structure  of.  39. 
Engagement,  extra-median,  621. 

in  breech  presentations,  258. 

in  brow  presentations,  255. 

in  face  presentations,  250. 

in  vertex  presentations,  229. 
Enterocele.  complicating  labour,  578. 

complicating  pregnancy.  477. 
Enteroptosis  during  pregnancy.  444. 
Entoderm,  91. 

Entrance  of  air  into  uterine  sinuses,   755. 
Epilepsy  during  pregnancy,  447. 

during  puerperium,  448. 
Epiphyses  in  syphilis.  514. 

separation  of.  during  extraction,  388. 
Episiotomy.  289. 
Ergot  in  abortion,  529. 

in  post-partum  haemorrhage,  729. 

use  of,  in  labour,  294. 


826 


OBSTETRICS 


Erysipelas  in  pregnancy,  437. 

relation  of,  to  puerperal  infection,  771. 

transmission  to  foetus,  437. 
Esbach's  albuminometer,  458. 
Escutcheon,  23. 

Estimation  of  date  of  confinement,  171. 
Ether,  291. 

Eustachian  valve,  138. 
Evisceration,  424. 
Evolution,  spontaneous,  688. 
Examination,  combined,  190. 

final,  312. 

preliminary,  during  pregnancy,  177,  275. 

vaginal,  during  labour,  280. 
pregnancy,  179. 
Exanthemata  in  pregnancy,  435. 
Exercise  during  pregnancy,  175. 
Exostosis,  producing  pelvic  de^rmities,  676. 
Expression  of  placenta,  272. 
Expression,  Ritgen's  method  of,  288. 
Expulsion  in  breech  presentations,  259. 

in  face  presentations,  251. 

in  vertex  presentations,  238. 
Extension  in  face  presentations,  251. 

in  vertex  presentations,  237. 
External  generative  organs,  23-35. 
External   rotation   in   breech   presentations, 
259. 
in  face  presentations,  251. 
in  vertex  presentations,  203,  238. 
External  version,   393. 

prognosis  of,  387. 
Extraction,  381. 

in  breech  presentations,  261,  3S1. 

indications  for,  381. 

in  frank  breech  presentation,  389. 

Mauriceau's  manoeuvre  for,  384. 

Prag  manoeuvre  for,  387. 
Extra-uterine  pregnancy,  532. 

abortion  of,  540. 

setiology  of,  532. 

anatomy  of,  545. 

associated  with  intra-uterine,  551. 

attachment  of  ovum  in,  548. 

cause  of  dystocia,  552. 

classification  of,  536. 

decidual  reaction  in,  535. 

deciduoma  malignum  in,  549. 

diagnosis  of,  552. 

eclampsia  in,  697. 

effects  upon  subsequent  childbearing,  552. 

fate  of  foetus  in,  544. 

formation  of  decidua  in,  546. 
of  placenta  in,  548. 

frequency  of,  532. 

hydatidiform  mole  in,  549. 

hydranmios  in,  549. 

interstitial,  539. 

lithopsedion  formation  in,  545. 

migration  of  ovum  in,  535. 

multiple,  551. 

mummification  in,  545. 

ovarian,   536. 

repeated,  551. 

rupture  of,  541. 

symptoms  of,  549. 


Extra-uterine    pregnancy,    terminations    of, 
540. 
treatment  of,  554. 
tubal,  539. 
uterine  decidua  in,  546. 

Face  presentations,  181,  246. 

abnormal  mechanism  in,  251. 

causation  of,  247. 

complicated  by  contracted  pelves,  633. 

conversion  of,  into  vertex,  253. 

craniotomy  in,  253. 

diagnosis  of,  247. 

forceps  in,  253,  377. 

frequency  of,  246. 

mechanism  of,  250. 

mistaken  for  breech,  258. 

perforation  in,  253. 

prolapse  of  cord  in,  747. 

symphyseotomy  in,  253. 

treatment  of,  252. 

version  in,  253. 
Facial  paralysis  following  forceps,  379. 
Faeces  of  infant,  317. 
Fallopian  tubes,  51-55. 

accessory,  54. 
lumina  of.  54. 
ostium  of,  54,  534. 

anatomy  of,  51. 

changes  in,  during  pregnancy,  150. 

ciliary  current  in,  53. 

diverticula  of,  54,  533. 

glands  of,  53. 

in  pregnancy,  150. 

position  of,  in  pregnancy,  146. 
False  labour,  551. 
False  promontory,  604. 
Fascia,  pelvic,  222. 

perineal,  222. 
Fastening  villi,  101,  114,  115. 
Fat  in  abdominal  walls  simulating  pregnan- 
cy, 168. 
Fatty  degeneration  of  placenta,  503. 
Fecundation,  El,  £3. 
Female  pronucleus,  85. 
Fertilization  of  ovum,  86. 
Fever  in  eclampsia,  695. 

in  labour,  780. 

in  puerperium,  304. 
Fibro-myomata    of  uterus,    complicating   la- 
bour, 574. 
Fillet,  391. 
Fimbria  ovarica,  51. 
Fimbriated  extremity  of  tube,  51. 
Fissure  of  nipple,  323,  808. 
Flat,  non-rhachitic  pelvis,  598. 

rhachitic  pelvis,  603. 
Flexion  in  breech  presentations,  259. 

in  brow  presentations,  255. 

in  face  presentations,  251. 

in  vertex  presentations,  232. 
Floating  kidney  during  pregnancy,  446. 
Foetal  circulation,  137. 

diseases,  516. 

dropsy.  516. 

dystocia,  678. 


INDEX 


827 


Foetal  heart-beat,'158. 

leukaemia,  ."Mi;. 

membranes,  122. 

monstrosities,  680. 

peritonitis,  684. 

syphilis,  511. 
KuMus,  abnormalities  of,  obstructing  labour, 

CIS. 

active  movements  of,  160. 

aiicurisiii  of,  (IS  1. 
ascites  of,  683. 
at  full  t  c-rm,  132. 

attitude  of,  L80, 

bladder,  distention  of,  6S4. 

calcification  of,  526. 

cardiac  lesions  in.  159. 

circulation  of,  137. 

coniprcssus,  330. 

congenital  hydrocephalus  of,  682. 

cranium   of,   135. 

cystic  kidneys  of,  684. 

death  of,  169. 

deformities  of,   681. 

due  to  amniotic  adhesions.  498. 

due  to  oligo-hydramnios,  498. 
development  of,  128. 
diameters  of  head  of,  136. 
digestive  functions  of,  142. 
diseases  of,  516. 
dissolution  of,  526. 
distention  of  bladder  of,  684. 
emphysema  of,  635. 
enlargement  of  abdomen  of,  683. 
estimation  of  age  of,  131. 
excessive  development  of,  679. 
excessively  large,  133. 
extraction  of,  381. 
general  dropsy  of,  516,  683. 
habitual  death  of,  345. 
habitus  of,  180. 
head  of,  135. 
headless,  6S1. 
heart-beat  of,  158. 
heart  sounds  of,  in  asphyxia,  750. 

in  pregnancy,  158. 
hydrocephalus  of,  682. 
infection  of,  with  Bacillus  aerogenes  cap- 

sulatus,  685. 
in  festu,  084. 
lanugo  of,  132. 
length  of,  1.32. 

lesions  of,  in  eclampsia,  705. 
maceration  of,  526. 
malformations  of,  680. 
meconium  of,  317. 
metabolism  of,  139. 

movements  of.  in  pregnancy,  142,  160. 
mummification  of,  526. 
negro,  132. 
nutrition  of,  137. 
•over-development  of,  133,  678. 
papyraceus,  330. 
passive  movements  of,  160. 
peritonitis  of,  6S4. 
physiology  of,  137. 
position  of,  1S2. 


I'u'liis,  presentation  of,   ISO. 

pressure  marks  on  bead  Of,  625. 

respiration  of,  l  12. 

sangulnolent  us,  .M-'c. 

signs  of  maturity  of,  132. 

size  of,  in  contracted  pelves,  G17. 
in   various   months,   12S. 

syphilis  of,  511. 

tumours  of  body  of,  085. 

tumour  of  liver  of,  084. 

urine  of,  141,  317. 

vernix  caseosa  of,  132. 

warmth  of,  142. 

weight  of,  132. 
Follicle,  Graafian.    (See  Graafian  Follicle.) 
Follicular  atresia,  70. 

epithelium,  00. 
Fontanelles,  135. 
Footling  presentation,  182. 
Foramen  ovale,  138. 
Forceps,  351. 

application  of,  369. 

as  dilator  of  cervix,  357. 

axis  traction,  374. 

cephalic  application  of,  360. 

Chamberlen's,  352. 

choice  of,  355. 

conditions  necessary  for  application  of,  357. 

contrasted  with  version,  634. 

delivery  in  oblique  occipito-posterior  posi- 
tion, 368. 
with  head  at  vulva,  362. 
with  high,  373. 
with  mid,  356. 
with  occiput  in  hollow  of  sacrum,  365. 

description  of,  351. 

facial  paralysis  following,  379. 

functions  of,  356. 

high,  359. 

history  of,  352. 

in  breech  presentations,  378. 

in  brow  presentations,  256. 

in  collision  of  twins,  334. 

in  contracted  pelves,  633. 

in  eclampsia,  707. 

in  face  presentations,  253,  377. 

in  frank  breech  presentations,  391. 

in  heart  disease,  356,  442. 

in     occipito-posterior    presentations,     242, 
368. 

in  prolapse  of  cord,  748. 

in  protracted  second  stage  of  labour,  566. 

in  rupture  of  uterus,  744. 

indications  for,  356. 

Levret's,  355. 

long,  355. 

low,  359. 

mid,  359. 

ovum,  529. 

Pajot's  manoeuvre,  376. 

pelvic  application  of,  361. 

perineal  tears  due  to,  365,  378. 

preparations  for  operation,  358. 

prognosis  of,  378. 

Saxtorph's  manoeuvre,  375. 

Scanzoni's  manoeuvre,  371. 


828 


OBSTETRICS 


Forceps,  short,  355. 

Simpson's,  351,  355. 

Tarnier's,  376.. 

to  afterconiing  head,  378,  388. 

upon  floating  head,  359. 
Forces  concerned  in  labour,  218. 
Fornix,  vaginal,  32. 

rupture  of,  during  labour,  735. 
Fossa  navicularis,  27. 

ovariea,  56. 
Fourchette,  25. 
Fractures  of  pelvis,  677. 

of  skull.     (See  Skull.) 
Freezing  point  of  blood,  139. 
Frontal  suture,  135. 

Fundal  incision  in  Csesarean  section,  405. 
Funic  souffle,  159. 
Funis.     (See  Umbilical  Cord.) 
Funnel-shaped  pelvis,  655. 

Galactocele,  812. 

Galactogogues,  320. 

Galactorrhcea,  809. 

Ganglion,  cervical,  49. 

Gangrene  of  lower  extremities  during  puer- 

perium,  799. 
Gas  bacillus.     (See  Bacillus  Aerogenes  Cap- 

sulatus.) 
Gasserian  fontanelle,  135. 
Generally  contracted,   flat,   rhachitic  pelvis, 
606. 

contracted  pelvis,  638. 

enlarged  pelvis,  638. 

equally  contracted  rhachitic  pelvis,  606. 
Germinal  epithelium,  59. 

spot,  66. 

vesicle,  66. 
Giant  cells  of  decidua,  112. 

of  placenta  in  lungs,  702. 

placental,  116. 
Gingivitis  in  pregnancy,  463. 
Glands,  Bartholin's,  27. 

cervical,  38. 

decidual,  107. 

Duverney's,  27. 

mammary,  152,  318,  807. 

salivary,  changes  of,  in  pregnancy,  463. 

thyroid,  cause  of  face  presentation,  247. 
changes  of,  in  pregnancy,  154,  448. 
foetal,  cause  of  dystocia,  685. 

uterine,  41. 

vaginal,  33. 

vestibular,  27. 

vulval,  24. 
Globulin,  increase  of.  in  eclampsia,  704. 
Glycerine,  use  of,  in  inducing  labour,  347. 
Glycosuria  during  pregnancy,  445. 

during  puerperium,  308. 
Goitre  in  pregnancy,  464. 
Gonococcus  in  Bartholin's  glands,  467. 

in  endometritis  decidua,  759. 

in  mammary   abscess,  811. 

in  ophthalmia  neonatorum.  317. 

in  puerperal  infection,  758. 
Gonorrhoea  in  pregnancy,  438. 

in  puerperium,  438. 


Gonorrhceal  endometritis,  438. 
Goodell's  cervical  dilator,  340; 
Graafian  follicle,  62,  64. 

degeneration  of,  70. 

rupture  of,  66. 
Gravitation  theory  as  to  production  of  pres- 
entation, 185. 
Greater  fontanelle,  135. 
Guerin's  line,  514,  601. 
Gumma  of  placenta,  516. 
Gut,  primitive,  94. 
Gynsecomastia,  807. 

Habitual  death  of  foetus,  345. 
Htemato-kolpos,  39. 
Hgematocele,  diffuse,  550. 
pelvic,  550. 
solitary,  550. 
treatment  of,  555. 
Haematoma  of  abdominal  walls,  465. 
of  broad  ligament,  543,  802. 
of  decidua,  526. 
of  liver,  in  eclampsia,  701. 
of  placenta,  504. 

of  sterno-cleido-mastoid  muscles,  388. 
of  umbilical  cord,  511. 
of  vagina,  571,  801. 
of  vulva,  28,  569,  801. 
puerperal,  801. 
subperitoneal,  741. 
Hsematosalpinx,  540. 
Hsematuria  during  pregnancy,  445.    . 
Haemophilia  during  pregnancy,  447. 
Haemorrhage,   accidental,  715. 
ante-partum,  713. 
concealed,  715,  727. 
curettage  in,  430. 
due  to  atony  of  uterus,  726. 
to  haemophilia,  726. 
to  inversion  of  uterus,  730. 
to  paralysis  of  the  placental  site,  726. 
to  placenta  praevia,  717. 
to  premature  separation  of  normally  im- 
planted placenta,  713. 
to  retention  of  placenta,  725. 
to  rupture  of  umbilical  cord,  725. 
during  normal  labour,  205. 

puerperium,   800. 
ergot  in,  729. 

from  velamentous  insertion  of  cord,  725. 
in  abortion,  527. 
in  cholera,  436. 
in   influenza,   437. 
in  multiple  pregnancy,  334. 
intraperitoneal,  541,  742. 
intra-uterine  douche  in,  428,  729. 

pack  in,  431,  429. 
manual  removal  of  placenta  for,  432,  728. 
post-partum.  725. 
unavoidable,  715,  718. 
use  of  salt  solution  in,  730. 
Hsemorrhagic  hepatitis,  700. 
Hair  of  pubis,  23. 
Hand  disinfection,  278. 

Harris's    method    of    dilating    the    cervix, 
348. 


INDEX 


829 


Head,  foetal,  chabges  in  shape  of,  in  brow 
presentations,  -•">•">. 
in  face  presentations,  251. 
in  vertex  presentations,  243. 

circumferences  of,  L36. 

dlamel  ers  of,  136. 

es(  imai  Ion  of  size  of,  629. 

fontanelles  of,  136. 

of  aew-born  child,  135. 

sc;ilp    tumour    on.      (See    Caput    Succeda- 
oeum.  i 

sutures  of,  135. 
Headache  in  eclampsia,  694. 

in  pregnancy,  177.  447.  4.">7. 
Head  folds,  89. 

lever  in  face  presentations,  251. 

in  vertex  presentations,  232. 
Heart,  diseases  of,  in  pregnancy.  441. 

foetal,  158. 
means  of  diagnosing  sex,  159. 
palliation  of,  159. 

hypertrophy  of,  in  pregnancy,  153. 
Hegar's  sign  of  pregnancy,  163. 
Hemianopsia  following  eclampsia,  696. 
Hemicephalus,  681. 
Hepatization  of  placenta,  503. 
Hepato-toxsemia,  456,  701.  703. 
Hermann's  forceps.   376. 
Hermaphroditism.  27. 
Hernia,  congenital,  of  foetus,  510. 

inguinal,  477. 

of  pregnant  uterus.  478. 

umbilical.  478. 

vaginal.  477. 
Herpes  gestationes.  449. 
Hicks's  sign  of  pregnancy,  164. 
High  forceps,  dangers  of,  373,  379. 
Hilum  of  ovary.  66. 
Hirst's  pelvimeter,  592. 
Hodge's  inclined  plane  of  pelvis.  3. 
Hook,  blunt.  424. 

Hour-glass  contraction  of  uterus.  568. 
Hubert's  forceps.  376. 
Hyalin  in  ovary.  C9. 
Hydatidiform  mole,  339,  344,  485. 

benign.  487. 

destructive,  488. 

in  extra-uterine  pregnancy,  549. 

malignant,  492. 

pathology  of,  486. 

relation  of.  to  deciduoma  malignum,  487. 

treatment  of,  489. 

vaginal  pack  in,  431. 
Hydrsemia  of  pregnancy.  133. 
Hydramnios.  339,  344.  493. 

acute,  496. 

in  double-ovum  twins.  495. 

in  extra-uterine  pregnancy.  549. 
Hydrocephalus,  682. 

craniotomy  in.  419. 

version  in.  395. 
Hydrorrhcea  gravidarum,  480. 
Hygiene    of    pregnancy.      (See    Pregnancy, 

Management  of.) 
Hymen.  28. 

absence  of  injury  at  childbearing,  30. 


Hymen,  annularis,  28. 

:ii  resla  or.  39,  569. 

carunculae  myrtiformes,  30. 

consistency  of,  28. 

denticulate,  28. 

development  of,  28. 

fimbriated,  :>. 

Imperforate,  28. 
cause  of  difficult  labour,  569. 

injuries  at  coitus,   29,   30. 

injuries  following  childbearfng,  30. 

operations  upon,  29. 

semilunaris.  28. 

septate,  28. 

structure  of,  28. 
Hyperemesis  gravidarum.  460. 
Hyperplasia  of  chorionic  villi.  506. 
Hypertrophic    elongation    of    cervix    during 

pregnancy,  477. 
Hypertrophy    of    uterus    during    pregnancy, 

145. 
Hypnotism  in  labour,  294. 
Hypoplastic  dwarf  pelvis,  642. 
Hysterectomy  during  pregnancy,  468.  575. 

for  myomata.  ."7". 

for  puerperal  infection,  789. 

supravaginal,  after  Caesarean  section,  406. 

total,  after  Csesarean  section,  407. 
Hysteria,  cause  of  nausea  of  pregnancy.  461. 

in  pregnancy,  448. 

Ice,  use  of,  in  hemorrhage,  729. 

Icterus  of  child.  318. 
during  pregnancy,  114. 

Ilio-pectineal  line.     (See  Linea  Terminalis.) 

Ilium,  3. 

Ileus,    due   to    retroflexed    pregnant    uterus, 
475. 

Imaginary  pregnancy,  168. 

Impetigo  Herpetiformis,  449. 

Implantation  of  ovum,  95,  111,  113. 

Impregnation,  81,  86. 

Incarceration  of  prolapsed  pregnant  uterus, 
476. 
of  retroflexed  pregnant  uterus,  474. 

Inclination  of  pelvis,  8. 

Incomplete  abortion,  527. 

Indigestion  during  pregnancy.  444. 

Induction   of  abortion.      (See   Abortion,    In- 
duction of.) 
of  premature  labour.    (See  Premature  La- 
bour, Induction  of.) 

Inertia  uteri,  563. 

Inevitable  abortion,  527. 

Infant,     i  See  New-born  Child.) 

Infantile  paralysis,  effect  upon  pelvis,  674. 
pelvis.  640. 

Infarcts  of  placenta,  503. 

Infectious  diseases  complicating  pregnancy, 
435. 

Inferior  strait.  6. 

Infibulation.  25. 

Influenza  during  pregnancy,  437. 

Infundibulo-pelvic  ligament,  56. 

Infundibulum,  51. 

Injuries  to  birth  canal,  734. 


830 


OBSTETRICS 


Innervation  of  uterus,  195. 
Innominate  bone,  2. 
Insanity  in  pregnancy,  465. 

lactational,  813. 

puerperal,  813. 
Insertio  velamentosa,  508. 
Insufflation    of   lungs   in   asphyxia    neonato- 
rum, 751. 
Interglandular  tissue  of  uterus,  42. 
Intermittent  contractions  of  uterus,  164. 
Internal  cell  mass,  88. 
Internal  generative  organs,  35-73. 

Fallopian  tubes,  51. 

ovaries,  55. 

uterus,  35. 
Internal  rotation,  232. 

causation  of,  234. 

in  breech  presentations,  258. 

in  brow  presentations,  255. 

in  face  presentations,  251. 

in  vertex  presentations,  232. 
Internal  secretion  of  ovaries,  58. 
Internal  version,  394. 
Interstitial  pregnancy,  539. 
Intervillous  blood  spaces,  114,  116,  118,  119. 
Intra-partum  eclampsia,  696. 

infection,  623,  781. 
Intra-uterine  douche,  428. 

dangers  of,  429,  787. 

indications  for,   428. 

in  post-partum  haemorrhage,  729. 

in  puerperal  infection,  787. 
Inversion  of  uterus,  730. 
Involution  of  uterus,  301. 
Ischiopagus,  680. 
Ischio-pubiotomy,  412,  647. 
Ischio-rectal  fossa,  222. 
Ischium,  3. 

spines  of,  3. 
Isthmic  pregnancy,  539. 
Isthmus  of  tube,  51. 

Jaundice  of  child,  318. 

of  mother,  444. 
Joints,  mobility  of,  during  pregnancy,  10. 

pubic,  10. 

relaxation  of,  during  pregnancy,  465. 

rupture  of,  during  labour,  623. 

sacro-iliac,  11. 
Justo-major  pelvis,  638. 
Justo-minor  pelvis,  638. 

Kidney,  changes  in,  during  pregnancy,  153. 
in  eclampsia,  699. 

cystic,  of  fcetus,  684. 

dislocation  of,  during  pregnancy,  446. 

dislocated,  complicating  labour,  578. 

floating,  during  pregnancy,  446. 

of  pregnancy,  154,  456. 

tumour  of,  complicating  labour,  578. 
Klien's  pelvimeter,  594. 
Knee  presentation,  182,  256. 
Knots  of  umbilical  cord.  510. 
Krause's  method  of  inducing  labour,  345. 
Kypho-rhachitic  pelvis,  660. 
Kypho-scolio-rhachitic  pelvis,  663. 


Kypho-scoliotic  pelvis,  663. 
Kyphosis,  654. 
Kyphotic  pelvis,  654. 

Labium  majus,  24. 
commissures  of,  24. 
development  of,  25. 
hernia  into,  25,  478. 
cedema  of,  464. 
Labium  minus,  25. 
fossa  navicularis,  27. 
fourchette.  25. 
frenulum  clitoridis,  25. 

labiorum.  25. 
nymphae,  25. 
prseputium  clitoris,  25. 
Laborde's  method  of  resuscitation,  751. 
Labour,  abdominal  contractions  during,  198. 
action  of  expellent  forces  in,  216. 
anaesthesia  during,  291. 
asepsis  in,  189,  287. 
bed,  preparation  of,  for,  282. 
caput  succedaneum,  243. 
cause  of  onset  of,  193. 
changes  in  arterial  tension  during,  199. 

in  perinseum  during,  223. 

in  pulse  during,  199. 

in  rectum  during,  224. 

in  respiration  during,  199. 

in  shape  of  head  in,  243. 

in  temperature  during,  199. 

in  uterus  during  first  stage  of.  213. 

in  uterus  during  second  stage  of,  216. 

in  vagina  and  pelvic  floor  during,  220. 
chill  after,  304. 
clinical  course  of,  199. 
cocaine  anaesthesia  during.  293. 
collapse  after,  753. 

complicated    by   bony    tumours    of   pelvis, 
676. 

by  compound  presentation  of  fcetus,  691. 

by  concealed  haemorrhage.  715. 

by  coxalgic  pelvis,  674. 

by  deformities  of  foetus,  681. 

by  eclampsia,  693. 

by    enlargement    of   abdomen   of   fcetus, 
683. 

by  excessive  size  of  child.  678. 

by  foetal  monstrosities,"  680. 

by  flat  pelvis,  618. 

by  generally  contracted  pelvis,  640. 

by   generally   contracted,    flat,    rhachitic 
pelves,  621. 

by  generally  enlarged  pelvis,  638. 

by  hydrocephalus,  682. 

by  injuries  to  cervix,  736. 

by  injuries  to  vagina,  734. 

by  intra-uterine  asphyxia,  750. 

by  inversion  of  uterus,  730. 

by  kyphotic  pelvis,  659. 

by  Naegele  pelvis,  646. 

by  osteomalacic  pelves.  635. 

by  paraplegia,  196,  198. 

by  pelvis  spinosa,  676. 

by  placenta  praevia,  717. 

by  post-partum  haemorrhage,   725. 


[NDEX 


>:J1 


Labour,    by    premature    separation    of   pla- 
centa, 713. 
complicated  by  prolapse  of  placenta,  7n;. 

by  prolapse  <>(  umbilical  curd.  7  IT. 

by  rbacbltlc  pelves,  618. 

by   Roberl   pelvis,  648. 

by  rupl  ure  of  I  be  uterus,  738; 

by  split  pelvis.  651, 

by   spondylolisthetic  pelvis,   667. 

i>y  transverse  presentation  <>f  fu-tus,  6st;. 

by  i  ii urs  u!'  foetus,  685. 

conduct  of,  275. 

liist  stage  of,  -77. 

second  stage  of,  282. 

third  stage  of,  27(t. 
contraction   of   uterine   ligaments   during, 

44.    188. 
course  of,  in  contracted  pelves,  G22. 
ileal li  during,  753. 
delivery  of  shoulders,  289. 
dilatal  ion  of  cervix,  215. 
dry.  201,   563. 
duration   of,   205. 

entrance  of  air  into  uterine  sinuses  dur- 
ing. 755. 
episiotomy  in,  289. 
ergot  during.  294,  563. 
examination  in,  283. 
false,  551. 
first  stage  of.  199. 
force  exerted  during,  197. 
forces  concerned  in,  218. 
formation  of  contraction  ring  during,  210, 
213. 
of  lower  uterine  segment,  209. 
haemorrhage  during,  205. 
hypnotism  in,  294. 
in  elderly  primiparae,  206. 
intra-uterine  pressure  during,  197. 
laceration  of  perinseum  during,  286. 
mechanism    of,    in    breech    presentations, 
256. 

in  brow  presentations,  253. 

in  face  presentations,  246. 

in  vertex  presentations,  227. 
moulding  of  head  in,  244. 
nervous  influences  during.  195. 
normal,  189,  275. 
obstructed.     (See  Dystocia.) 
painful,  563. 
painless,  197. 
pains  of,  196. 
perineal  tears  in,  203. 
phenomena,  clinical,  of,  199. 
physical   changes   during  uterine   contrac- 
tions, 198. 
physiology   of.   193. 
precipitate,  567. 
prediction  of  date  of.  171. 
premature.  521. 

preparations   for,   on   part   of  patient   and 
nurse,  275. 
on  part  of  physician,  276. 
profound  mental  depression  during,  754. 
prolonged.    562. 
protection  of  the  perinseum  in,  2S6. 


Labour,   pulmonary  embolism  during,  755. 

repair  of  perineal  tears,  295. 
rubber  gloves,  use  of,  during,  278. 
nipt  ure  of  membranes  In,  200.  ii]7. 
second  stage  of,  201. 
shock  during,  753. 
stages  of,  199. 
syncope  during,  754. 
tardy,  562. 

temperature  in,  199,  780. 
third  stage  of,  204,  264. 
tying  of  cord  in.  290. 
vaginal  examination  during,  280. 
Lactation,  318. 

atrophy  of  uterus,  803. 
Lactosuria  during  pregnancy,  445. 

during  puerperium,  307. 
Lambdoid  suture,  135. 
Langhans's  layer  of  chorion,    102,    115.   117, 

122. 
Lanugo,  132. 
Laparo-elytrotomy,  410. 
Laparotomy,  for  colpaporrhexis.  735. 
for  deep  cervical  tears,  738. 
for  puerperal  infection,  789. 
for  rupture  of  uterus,  744. 
in  extra-uterine  pregnancy.  554. 
in     treatment     of     retroflexed     pregnant 
uterus.  475. 
Lateral  curvature  of  spine,  661. 
displacement  of  pregnant  uterus.  476. 
flexion  in  breeeh  presentations,  259. 
placenta  prsevia,  717. 

plane      presentations.        (See      Transverse 
Presentation.) 
Laxatives  in  puerperium,  311. 
Lead  poisoning  during  pregnancy,  449. 
Leg-holder,  358. 
Leopold's  ovum,  96. 
Lesser  fontanelle,  135. 
Leucocytosis  in  puerperium,  153,  306. 
Leucomaines   in  eclampsia,   704. 
Leukaemia  during  pregnancy,  344,  449. 
Levator  ani  muscle,  221. 
dystocia  due  to,  571. 
injuries  to,  during  labour,  735. 
Levret's  forceps,  355. 
Life,  142. 

perception  of,  166. 
Ligaments,  broad,  43. 
cardinal,  of  Kocks,  44. 
ilio-sacral,   4. 
irifundibulo-pelvic,  44. 
of  uterus,  43. 
ovarian,  56. 
recto-uterine,  45. 
pubic.  10. 
round.   44. 
sacro-sciatic,  6. 
suspensory,  of  ovary,  44,  56. 
utero-sacral,  45. 
Ligamentum,  aeuatum  pubis,  10. 
latum.  43. 
ovarii.    56. 
teres,  44. 
transversale  colli,  44. 


832 


OBSTETRICS 


Linea  terminalis,  2. 
Liquor  folliculi,  64. 
Lithoppedion,  520,  545. 

Liver,  acute  yellow  atrophy  of,  during  preg- 
nancy, 444. 

changes  in,  in  eclampsia,  700. 

syphilitic  cirrhosis  of,  513. 
Lochia,  bacteria  in,  306. 

bacteriological  examination  of,  783. 

in  puerperal  infection,  778. 

retention  of,  804. 
Lochia-metra,  804. 
Locked  twins,  334. 
Longings  in  pregnancy,  166. 
Loops  in  umbilical  cord,  510. 
Lower  uterine  segment,  209. 

during  puerperium,  220,  303. 

history  of,  209. 

nature  of,   211. 
Lungs,  changes  in,  during  pregnancy,  154. 

lesions  of,  in  eclampsia,  702. 
Lutein  cells,  64,  67,  69. 
Luxation     of    femur,     effect     upon     pelvis, 

673. 
Lymphatics  of  ovaries,  57. 

of  tube,  54. 

of  uterus,  48. 

of  vagina,  34. 
Lymphoid  nodules  in  endometrium,  42. 

Maceration  of  foetus,  512,  526. 
Macula  embryonalis,  88. 
Malaria  during  pregnancy,  439. 

in  puerperium,  781,  814. 

transmission  of,  to  child,  440. 
Male  pronucleus,  87. 
Mammae.    (See  Breasts.) 
Management  of  pregnancy,  175. 
Mania.    (See  Insanity.) 
Manual  removal  of  placenta,  273,  432,  728. 
Marginal  insertion  of  cord,  508. 

placenta  prsevia,  717. 
Marginate  placenta,  503. 
Margo  placentae,  504. 
Markstrange,  57. 
Martin's  pelvimeter,  584. 
Masculine  pelvis,  640. 
Mastitis,   810. 
Maturation  of  ovum,  84. 
Maturity  of  foetus,  signs  of,  132. 
Mauriceau's  manoeuvre,   384. 
Measles  during  pregnancy,  436. 

during  puerperium,   815. 

intra-uterine,  436. 
Mechanism  of  labour,  complicated  by  fcetal 
monstrosities,  680. 

in  breech  presentations,  258. 

in  brow  presentations,  254. 

in  contracted  pelves,  618. 

in  face  presentations,  250. 

in  oecipito-posterior  presentations,  238. 

in  transverse  presentations,  687. 

in  vertex  presentations,  227. 
Meckel's  diverticulum,  125. 
Meconium,  317. 
Medulla  of  ovary,  57. 


Medullary  cords,  57. 

groove,  89. 

ridges,  89. 
Membrana  granulosa,  64. 
Membranes,  foetal,  122. 

method  of  rupturing,  283. 

rupture  of,  201. 
in  contracted  pelves,  622. 
Membranous  placenta,  501. 
Memory,  loss  of,  in  eclampsia,  696. 
Menopause,  74. 
Menses,  cessation  of,  in  pregnancy,  164. 

persistence  of,  in  pregnancy,  165. 
Menstrual  cycle,  76. 

decidua,  77. 

nerve,  78. 

wave,   77. 
Menstruation,  74. 

after  ovariotomy,  78. 

anatomical  changes  in,  74. 

causation  of,  76. 

cessation  of,  in  pregnancy,  164. 

in  infants,  74. 

participation  in.  by  tube,  78. 

persistent,  74. 

precocious,  74. 

relation  of,  to  ovulation,  76. 
Mental  and  emotional  changes  during  preg- 
nancy, 166. 

depression  during  labour,  754. 

derangement  following  eclampsia,  696. 
in  pregnancy,  465. 
Mento-iliac    presentation.    (See    Face    Pres- 
entations.) 
Mercurial      poisoning      from      intra-uterine 

douche,  429. 
Merttens's  ovum,  95. 
Mesoblastic  somites,   90. 
Mesoderm,  89. 
Mesodermic  area,  89. 
Mesosalpinx.  44,  51. 
Mesovarium,  56. 
Metritis  in  pregnancy,  482. 

puerperal,  768. 
Meyer's  conjugate.  9. 
Michealis's  rhomboid.  587. 
Migration  of  ovum,  78. 
Milk,  anatomy  of.  319. 

corpuscles  of,  319. 

cow's,  324. 

human,  319. 

modified.  324. 

fever,  305,  7S1. 

leg.    (See  Phlegmasia  Alba  Dolens.) 
Miscarriage,  521. 
Missed  abortion,  530. 

labour,  551. 
Mole,  525. 

blood,   525. 

carneous,  525. 

destructive,  4S8. 

fleshy,  525. 

hydatidiform,  585. 

tubal,  541. 

uterine,  525. 
Molecular  concentration  of  blood,  139. 


i.\i)i:x 


S33 


Monsters,  680. 

Mons  veneris,  23. 

Montgomery 's  glands,  152. 

Morales's  forceps,  376. 

Morning  sickness,  L65. 

Morula,  ST. 

Movements  of  fu-tus  during  pregnancy,  1G0. 

Mulberry  mass.  87. 

Miillerlan  ducts,  49. 

MUller's  method  i>f  impression  of  head,  029. 

Multiple  pregnancy,  326. 

acardla  In,  329,  495,  G81. 

course  of  labour  in,  332. 

diagnosis  of,   331. 

etiology  of,  326. 

foetus  papyraceus  in,  330. 

frequency  of,  326. 

haemorrhage  in,  334. 

in  hydramnios,  495. 

in  tubes,  551. 

mummification  of  foetus  in,  330. 

relation  of  placenta  and  membranes  in,  328. 

size  of  children  in.  330. 

t  reatment  of.  333. 
Muscle  fibres  of  pregnant  uterus,  14o. 

rhomboids  of  uterus,  148. 
Muscular  contractures  in  osteomalacia,  612. 

palsies  in  osteomalacia,  612. 
Musculature  of  non-pregnant  uterus,  43. 

of  pregnant  uterus,  146. 

of  tube,   52. 
Myocarditis  during  pregnancy,  443,  455. 
Myoma  of  uterus.  Caesarean  section  in,  403. 

complicating  labour,  574. 
pregnancy.  340.  344. 
Myomectomy  during  pregnancy,  575. 
Myometrium.  43. 
Myxoma  ehorii.  4S6. 

fibrosum  of  placenta,  506. 

Nabothian  follicles,  38. 

Naegele's  obliquity,  231,  619. 

Naegele  pelvis.  642. 

Nausea  and  vomiting  in  pregnancy,  165,  460. 

Negro  foetus,  characteristics  of,  132. 

Nephritis,  chronic,  during  pregnancy,  445. 

following  eclampsia,  698. 
Nerves  of  clitoris,  26. 

of  ovaries,  57. 

of  uterus.  49. 
Nervous  system  in  pregnancy,  154. 
Neuralgia  during  pregnancy.  447. 
Neurenteric  canal,  90. 
Neuritis  during  pregnancy,  447. 

puerperal,  S06. 
New-born  child,   artificial  feeding  of,  323. 

asphyxia  of.  749. 

care  of.  315. 
eyes  of,  316. 

circulatory  changes  in.  314. 

ductus  arteriosus  of,  138,  314. 

feeding  of,  321. 

foramen  ovale  of,  148,  314. 

head  of,  135. 

icterus  of,  317. 

jaundice  of,  318. 

04 


New-born  child,  length  of.   L82. 
loss  of  weight  of,  318. 
nursing  of,  321. 
ophl  halmia  of,  317. 

sc.\    Of,     1  12. 
si  0OlS  Of,  •"•17. 

umbilical  cord  of,  315. 

urine  of,  -'117. 

weight    of,    132. 
Nipples,  abnormalities  of,  808. 

care  of,  during  pregnancy,  176. 
during  puerperium,  323. 

cracked,  in;.  323,  811. 

depressed.   177,  SON. 

fissures  of,  323,  808. 
Nipple  shield.  177,  323. 
Nomenclature  of  presentation,  182. 
Notochord,  91. 
Nuchal  presentation,  692. 
Nuck,  canal  of.  25. 

Nuclein,  use  of.  in  puerperal  infection,  791. 
Nucleus,  segmentation,  87. 
Nursing,  321. 
Nymphse,  25. 

Obliquely  contracted  pelvis,  642. 
Obstetrical  outfit,  276. 

paralysis.     (See  Paralysis,  Obstetrical.) 

surgery.    (See  Operations,   Obstetrical.) 
Obstructed  labour.    (See  Dystocia.) 
Occipitoanterior    presentations.      (See    Ver- 
tex Presentation.) 
Occipito-posterior   presentations.    (See    Ver- 
tex Presentation.) 
(Edema  in  pregnancy,  152,  154,  463. 
Oligo-hydramnios,  498. 
Omphalo-mesenteric  vessels,  137. 
Oophoritis,  puerperal,  768. 
Operations,  obstetrical,  336. 

accouchement  force,  347. 

Csesarean  section,  401. 

cleidotomy,  426. 

craniotomy,  418. 

curettage,  429. 

decapitation,  424. 

douche,  427. 

embryotomy,  423. 

evisceration,  424. 

extraction  in  breech  presentations,  381. 

forceps,  351. 

induction  of  abortion,  338. 
premature  labour,  341. 

intra-uterine  pack,  432. 

laparo-elytrotomy,  410. 

manual  removal  of  placenta,  432. 

preparations  for,  336. 

symphyseotomy,  410. 

tampon,  431. 
Ophthalmia.  316. 

neonatorum,  317. 
Organ  of  Rosemiiller,  44. 
Os  externum,  37. 

innominatum.  2. 

internum.  36. 
Os  tincae,  37. 
Osteo-chondritis  syphilitica,  514. 


S34 


OBSTETRICS 


Osteomalacia,  clinical  history  of,  610. 

pathology  of,  611. 

pelvis  in,  613. 
Osteomalacic  pelvis,  613. 
Ova,  early  human,  95,  128. 
Ovarian  abscess,  768. 

artery,  46. 

epithelium,  57. 

pregnancy,   536. 

tumours,  Csesarean  section  in,  403. 
complicating  pregnancy,  168,  340,  344. 
Ovaries,  55. 

accessory,  58. 

anatomy  of,  55. 

changes  in,  in  pregnancy,  150. 

corpus  luteum  of,  66. 

development  of,  59. 

epithelium  of,  57. 

erectility  of,  57. 

ganglion  of,  57. 

Graafian  follicle,  62. 

hilum  of,  56. 

in  osteomalacia,  636. 

internal  secretion  of,  58. 

in  young  child,  61. 

ligament  of,  56. 

microscopic  structure  of,  61. 

peritonseum,  relations  of,  to,  52. 

position  of,  in  pregnancy,  150. 

relation  of,  to  Wolffian  body,  57. 

transplantation  of,  58. 
Ovariotomy  during  pregnancy,  577. 
Ovate  pelvis,  642. 

Over-rotation  in  breech  presentation,  259. 
Ovula  Nabothi,  38. 
Ovulation,   76. 

during  pregnancy,  150. 

relation  of,  to  menstruation,  76. 
Ovum,  74. 

abdominal  pedicle,  97. 

allantoic  vesicle,  95. 

allantois  of,  95,  123. 

amnion  of,  93. 

area  opaca  of,  89. 

area  pellucida  of,  89. 

Bauchstiel  of,  97. 

blastodermic  vesicle,  87. 

chorion  of,  93,  95,  122. 

cleavage  of,  86. 

ccelome  of,  91. 

deutoplasm  of,  66. 

development  of,  87. 

discharge  of,  from  ovary,  66,  76. 

diseases  and  abnormalities  of,  485. 

ectoderm  of,  S9. 

embryonic  area  of,  88. 

embryonic  shield  of,  89. 

entoderm  of,  89. 

female  pronucleus  of,  85. 

fertilization  of,  86. 

germinal  spot,  66. 

germinal  vesicle,  66. 

head  folds  of,  89. 

impregnation  of,  81. 

internal  cell  mass  of,  88. 

in  transit  through  tube,  88. 


Ovum,    Leopold's,  96. 

macula  embryonalis  of,  88. 

male  pronucleus  of,  87. 

maturation  of,  84. 

mature,  65. 

medullary  groove  of,  89. 

medullary  ridges  of,  89. 

Merttens's,  95. 

mesoblastic  somites  of,  90. 

mesodermic  area  of,  89. 

mesoderm  of,  89. 

migration  of,  78. 
external,  79. 
internal,  80. 

morula  of,  87. 

neurenteric  canal  of,  90. 

notochord,  91. 

parietal  zone  of,  90. 

Peters' s,  95. 

physiology  of,  74,  87. 

place  of  meeting  with  spermatozoa,  80. 

polar  bodies  of,  85. 

premature   expulsion   of.      (See   Abortion.) 

primary  segments  of,  90. 

primitive  folds  of,  89. 

primitive  streak  of,  89. 

primordial,  59. 

pronucleus,    85. 

protovertebrse  of,  90. 

Reichert's,  88. 

segmental  layer  of,  90. 

segmentation  nucleus  of,  87. 

segmentation  of,  87. 

size  of,  65. 

somatopleure  of,  91. 

Spee's,    90. 

splanchnopleure  of,  91. 

trophoblast  of,  93,  113. 

tuberculosum,  526. 

umbilical  vesicle  of,  93,  124. 

vitelline  membrane  of,  87. 

with  double  nuclei,  63,  327. 

yolk  of,  67. 

yolk-sac  of,  93,  128. 

zona  pellucida  of,  65. 
Oxytocics,  indications  for  use  of,  565. 

Pack.    (See  Tampon.) 
Painless  labour,  197. 
Pajot's  manoeuvre,  376. 
Palfyn's  forceps,  354. 
Palpation,  178,  186. 

in  anterior  occipito-iliac  presentations,  228. 

in  breech  presentations,  257. 

in  brow  presentations,  254. 

in  face  presentations,  247. 

in  posterior  iliac  presentations,  239. 

of  cephalic  prominence,  187. 

of  contraction  ring.  188,  743. 

of  foetal  heart-beat,  159. 

of  lower  uterine  segment,  188. 

of  outlines  of  fcetus,  160. 

of  round  ligaments,  188. 

of  shoulder,  188. 

through  perinpeum,  284. 
Palper  mensurateur,  629. 


INDEX 


si." 


Pampiniform  plexus,  -Is. 
Paradoxical  Incontinence,  -174. 
Paralysis,   Duchenne's,  806. 

during  pergnancy,  447. 

during  puerperlum,  805. 

facial,  following  forceps,  379. 

oiisttMi-ical.  ::v\  mi:.. 

..I"  placenta]  site,  726. 
Parametritis,  767,  77s 
Parametrium,  44. 
Paraplegia  complicating  labour,  196,  198. 

during  pregnancy,  447. 
Para-nretbral  ducts,  27. 
Parietal  layer,  90. 
ran. varium,   44. 
Partial  placenta  previa,  717. 
Parturition.    (See  Labour.) 
Partus  conduplicato  corpore,  689. 
Pathology  of  labour,  562. 

of  pregnancy,  435. 

■  if  puerperlum,  757. 
Pelvic  abscess,  768,  789. 

cavity,  3. 

cellulitis     following     puerperal     infection, 
768,   789. 

fascia,  222. 

floor.  220. 
anatomy  of,  220. 
changes  in,  during  labour,  223. 

joints,   relaxation  of.   in  pregnancy.   465. 

peritonitis    following    puerperal    infection, 
779. 
Pelvigraph.  593. 
Pelvimetry,  by  use  of  X  ray.  504. 

external,  584. 

in  pregnancy.  178,  584. 

internal,  590. 
Pelvis.  1. 

acanthopelys,  676. 

anatomical  conjugate.  6. 

anatomy  of,   1-22. 

articulations  of,  10. 

assimilation,  651. 

axis  of,  10. 

cavity  of.  3. 

changes  in  size  of.  11. 

chondrodystrophy  dwarf.  641. 

coccyx.   2. 

comparison  of.  11. 

conjugata  diagonalis,  6. 

conjugata  vera.  5. 

contracted.    (See  Contracted  Pelvis.) 

coxalgic,  672. 

cretin  dwarf,  642. 

development  of.  16. 

diameters  of.  4. 

dolichopellic,  15. 

double  luxation  of  femora.  674. 

double  Naegele,  643. 

dwarf.  641. 

exostosis  of,  603,  676. 

false.  3. 

flat  non-rhachitic,  598. 

flat  rhachitic.  603. 

fractures  of.   677. 

funnel-shaped,  655. 


Pelvis,  generally  contracted,  63S. 

flat   rhachitic,  606. 
generally  enlarged,  638. 
generally  equally  contracted  rhachitic,  606 
hypoplastic  dwarf,   642. 
inclination  of,  8. 
inclined  planes  of,  3. 
infantile,  16,  640. 

paralysis,  074. 
inferior  strait,  6. 
Inlet  of,   i. 
innominate  line,  3. 
ischial   spines.   .:. 
Ischium,  3. 
joints  of.   10. 
justo-major,  638. 
justo-minor.  638. 
kypho-rhachitic,  660. 
kypho-scolio-rhachitic,  663. 
kypho-scoliotic,  663. 
kyphotic.   654. 
ligaments  of,  10. 
linea  terminalis,  3. 
male,  13. 
masculine.   640. 
mesatipellic,  15. 

movements  of.  in  joints,  10.  405. 
muscles  of.  221. 
Xaegele.  642. 
nana.   042. 
nimis  parva,  638. 
normal  conjugate  of,  9. 
oblique  conjugate  of.  6. 
obliquely  contracted.  642. 
obstetrical  conjugate  of,  6. 
obtecta,  655. 
of  new-born  child,  16. 
ossification  of,  17. 
osteomalacic,  613. 
outlet  of.  6. 
ovate,  642. 

plana   Deventeri.   598. 
plana  osteomalacia,  613. 
plane  of  greatest  pelvic  dimension,   7. 
plane  of  least  pelvic  dimension,  8. 
planes  of.  4. 
platypellic,  15. 
pseudo-osteomalacic,  607. 
pubis.  4. 

racial  differences  in.  15. 
rhachitic.  601. 

dwarf.   642. 
Robert.   648. 

sacro-cotyloid  diameter  of.  5. 
sacro-iliac  synchondrosis,  10. 
sacrum.  3. 
scolio-rhachitic,  661. 
scoliotic.  661. 
second  parallel  of.  8. 
separation  of.  during  labour,  1. 
sexual  differences  in.  13. 
simple  flat.  598. 
soft  parts  of.  221. 
spinosa.  005.  676,  745. 
split,  649. 
spondylolisthetic,  664. 


836 


OBSTETRICS 


Pelvis,   spondyliz&me,  658. 

straits  of,   4. 

superior  strait  of,  4. 

symphysis,  absence  of,  649. 

symphysis  of,   relaxation  in,  465. 

symphysis  pubis,  10. 

transformation  of  foetal  into  adult,  IS. 

transversely  contracted,  648. 

true,  3. 
conjugate  of,    5. 
dwarf,   642. 

tumours  of,  676. 

unilateral  luxation  of  femur,  673. 

variations  in,  12. 

Veit's  main  plane  of,  8. 

with    imperfect    development    of    sacrum, 
651. 
Pendulous  abdomen.  472. 
Perforation.    (See  Craniotomy.) 

of  Douglas's  cul-de-sac,  745. 

of  uterus,   744. 
Perineal  fascia,  222. 

gutter,   224. 

muscles,  222. 

tears,  after-treatment  of,  298. 
central,    297. 
frequency  of.  203,  286. 
mode  of  production  of,  287,  734. 
prevention  of,  2S7. 
repair  of,  295. 
Perinseum,  anatomy  of,  222. 

changes  in,  during  labour,  224. 

lacerations  of,  286,  295. 

protection  of,  286. 

rigid,  569. 
Peritonitis,  puerperal,  768. 
Peri-uterine  inflammation  in  pregnancy,  483. 
Pernicious  ansemia  during  pregnancy,  448. 

vomiting  of  pregnancy,  460. 
Pessary  in  treatment  of  retroflexed  pregnant 

uterus,  475. 
Peters's  ovum,  95. 
Pfliiger's  ducts,  59. 
Phantom  tumours  in  diagnosis  of  pregnancy, 

168. 
Phlebitis,  femoral,  769,  780,  798. 

uterine,  764. 
Phlebotomy  in  eclampsia,  709. 
Phlegmasia  alba  dolens,   during  pregnancy, 
443. 

in  puerperium,  769,  780,  798. 
Phloridzin  diabetes,  142. 
Phthisis  of  placenta,  503. 

complicating  pregnancy,  438. 
Physometra,  623. 

Pigmentation,  changes  in,  during  pregnancy, 
154. 

in  negro  baby,   132. 

in  pregnancy,  166. 
Placenta,  113. 

abnormalities  in  size  of,  499. 

abnormalities  in  weight  of,  500. 

adherent.  273.  508. 

anatomy  of.  119. 

angeioma  of,  506. 

annular,  499. 


Placenta,   apoplexy  of,  503. 
artificial  separation  of,  432. 
at  full  term,  119. 
atrophy  of,  503. 
basal  plate  of,  116. 
battledore,  508. 
bipartita,   500. 
bruit  of,  159. 
calcification  of,  507. 
canalized  fibrin  of,  116,  118. 
cell  nodes  of,  114.  115. 
changes  in,  in  eclampsia,  704. 
circular  sinus  of,  122. 
circumvallata,  503. 
closing  plate  of,  116. 
cotyledons  of,  121. 
cysts  of,  505. 
decidual  islands  of,  116. 
development  of,  113. 
diagnosis  of  position  of,   by  palpation   of 

round  ligaments,  188. 
dimidiata,  500. 
diseases  of,  503. 
duplex,  501. 
epithelium  of.  115. 
expression   of,  270. 

by  author's  method,  272. 

by  Crede's  method,  270. 
expulsion  of,  by  Duncan's  method,  266. 

by  Schultze's  method,  266. 
fatty  degeneration  of,  503. 
f  enestrata,   500.  • 
fibroma  of,  506. 
functions  of.  119.  137,  139. 
giant  cells  of,  116. 
gumma   of,    516. 
hepatization  of,  503. 
in  albuminuria,  505. 
in  extra-uterine  pregnancy,  548. 
in  latter  half  of  pregnancy,  116. 
in  multiple  pregnancy,  328. 
in  placenta,  507. 
in  syphilis.  500. 
infarcts  of,  503. 
inflammation  of.  507. 
intervillous  blood  spaces  of,  114,  116. 
manual  removal  of.  273,  432,  728. 
marginata.  503. 

mechanism  of  separation  of,  264. 
membranacea.   501. 
membranes  of.  119.  122. 
mode  of  delivery  of,   265. 
mode  of  extrusion  of,  265. 
multiple,  in  single  pregnancy,  500. 
myxoma  fibrosum  of,  506. 
new  growths  in,  506. 
oedema  of,  516. 
osmotic  pressure  in,  705. 
phthisis  of,  503. 
polyp  of.  801. 
prsevia,  503.  717. 

accouchement  force  in,  724. 

aetiology  of.  719. 

Cesarean  section  in.  724. 

developed  from  reflexa  placenta,  720. 

diagnosis  of,  722. 


i\Di:.\ 


837 


Placenta  praevia,  frequency  of,  718. 

Induction  of  premature  labour  for,  345, 

podallc  version  in.  394,  ~'l'.\. 
prognosis  of,  '-'-■ 
symptoms  of,  721. 
treatmenl   of,  '-'■'<■ 
vaginal  pack  In,  431,  724. 
premature  separation  of,  713. 
prolapse  of,  715. 
reflexa,  720. 

retention  of,  cause  <>f  haemorrhage,  725. 
sarcoma  of,  5(io. 
schlrrus  i>r.  503. 
senility   of,   504. 
septuples,  501. 
siie  of,  post  partum,  302. 
Situation  of,  in  utcro,  2G4. 
spuria.  .".(I— 
succenturiata,  5ii2. 
syncytium  of,  114. 
syphilis  of,  515. 

transmission  of  substances  through,  139. 
triplex.  501. 
trophoblast  of,  114. 
t ruffe.  504. 
tuberculosis  of.  507. 
tumours  of,  506. 
velamentous,  508. 
vessels  of,  116,   119,   121. 
vicious  insertion  of,  718. 
villi  of.  fastening,  114. 
weight  of,  119. 
Placental  forceps,  341. 
transmission,  139. 
period,  264. 
amount  of  blood  lost  during,  270. 
clinical  picture  of,  268. 
haemorrhage  during.  273. 
management  of,  270. 
mechanism    of    separation    of    placenta, 

264. 
mode  of  extrusion  of  placenta,  265. 
normal  situation  of  placenta  in  utero,  264. 
souffle,  159. 
Placentitis,  503,  507. 
Planes  of  pelvis.  4. 
Plasmodium,  chorionic.  102. 
Pleurisy  in  puerperal  infection,  780. 
Plexus  hypogastric,  49. 

pampiniform.  48. 
Plicae  palmatfe,  37. 
Pneumonia  alba,  513. 
during  pregnancy,   437. 
during  puerperium,  814. 
Podalic  version,  394. 
in  brow  presentations.  256.  394. 
in  face  presentations,  253,  394. 
in  oceipito-posterior  presentations,  243,  394. 
indications  for,  394. 
technique  of,  395. 
Polar  body,  85. 
Polygalacia,  809. 
Polymastia,  807. 

Polypus,  fibrinous,  causing  haemorrhage,  801. 
Porro  Caesarean  section,  401,  406,  40S. 


Portio  vaginalis  of  cervix,  30. 

Position  of  foetus,  L82. 

Positive  sinus  of  pregnancy,  158. 

Pusl   iiinrleiii  Ca-sareau  section,  410. 

delivery,  755. 
Post-partum  eclampsia,  096. 
haemorrhage,  725, 
ael  lology  of,  "25. 
clinical  history  of,  720. 

treat  inellt    of,    729. 

Posture,   in  first   stage  of  labour,  200,  282. 

in   second  stage  of  labour,  201,  282,  285. 
Prague  manoeuvre,  387. 
Precipitate  labour,  567. 
Pregnancy,   145. 
abdominal,  544. 

enlargement  during,  161. 
abnormalities  of  pigmentation  in.  450. 
acardia  in  multiple,  329,  681. 
accidents  during,  450. 
acute  endometritis  during,  481. 
acute  infectious  diseases  in.  344,  435. 
acute  oedema  of  cervix  during,  477. 
acute  yellow  atrophy  of  liver  in,  444. 
albuminuria  during,  153,  455. 
amaurosis  in,  448. 
amenorrhoea  during,  76,  164. 
ampullar,   539. 
anaemia,  pernicious,  in,  344. 
anomalies  and  diseases  of  ovum.  485. 
anteflexion  of  uterus  during,  159,  472. 
anteversion  of  uterus  during,  472. 
anthrax  in,  438. 
apoplexy  in,  448. 
appendicitis  in,  451. 
areola  in,  152,  165. 
asthma  in,  443. 

atrophic  endometritis  decidua  during,  481. 
auto-intoxication  in,  455. 
ballottement  in,  160. 
bladder  and  rectum,  changes  in,  154,  176, 

177. 
blood  changes  in,  153. 
bowels  in,  176. 

Braxton  Hicks's  sign  of,  164. 
breasts,  care  of,  during,  176. 
broad  ligament,  543. 

changes  in,  during,  149. 
carcinoma  of  cervix  during,  340. 
cardiac  lesions  in,  343. 
cephalalgia  in,  447,  457,  694. 
Chadwick's  sign  of,  166. 
changes  in  abdominal  wall  during.  151. 

bladder  during,  154. 

blood  during.  154. 

breasts  during,  152,  165. 

cervix  during,  164. 

heart  during,  153. 

kidneys  during,   153. 

lungs  during,  154. 

maternal  organism  during.  145. 

nervous  system  during,  154. 

ovaries  during,  150. 

pigmentation  during.  154. 

size,    shape,    and   consistency   of   uterus 
during,  162. 


838 


OBSTETRICS 


Pregnancy,  thyroid  during,  154. 

tubes  during,  150. 

uterus  during,  145. 

vagina  during,   150. 

weight  during,  154. 
cholera  in,  436. 
chorea  in,  344,  447. 
chronic  infectious  diseases  *n,  438. 
chronic  nephritis  in,  445. 
cloasrna  in,  450. 
clothing  during,  176. 
coitus  in,  176. 

colpo-hyperplasia  cystica  during,  467. 
constipation  during,  154,  176,  444. 
contracted  pelves  during,  340. 
cravings  during,  166. 
cystitis  in,  447. 
death  of  foetus  during,  169. 
decidua  polyposa  during,  480. 
dental  caries  in,  463. 
depressed  nipples  in,  177. 
dermatitis  herpetiformis  in,  449. 
diabetes  in,  445. 
diagnosis,  differential,  of,  167. 
diagnosis  of,  157. 

of  death  of  foetus  in,  169. 

of  multiple,  331. 
diastasis  of  recti  muscles  during,  152,  478. 
diet  during,  176. 

diffuse  thickening  of  decidua  during,  480. 
discoloration  of  mucous  membrane  in,  166. 
diseases  of  alimentary  tract  and  liver  in, 
444. 

of  blood  in,  448. 

of  cervix  during,  468. 

of   circulatory    and    respiratory    systems 
in,  441. 

of  decidua  during,  479. 

of  kidneys  and  urinary  tract  in,  445. 

of  nervous  system  in,  447. 

of  ovum  during,  339. 

of  skin  in,  449. 

of  vulva  and  vagina  during,  467. 
dislocation  of  kidney  in,  446. 
displacements  of  uterus  during,  472. 
distinction   between  first  and  subsequent, 

169. 
disturbances  of  vision  in,  448. 
duration  of,  128,  170. 
dyspnoea  in,  444. 
eclampsia  in,  460,  693. 
ectopic.    (See  Extra-uterine  Pregnancy.) 
emesis  in,  165,  460. 
emphysema  during,  443. 
endocarditis  in,  443. 

endometritis  decidua  cystica  during,  481. 
endometritis  during,  479. 
enteroptosis  in,  444. 
epilepsy  in,  447. 
erysipelas  in,  437. 

estimation  of  date  of  confinement,  171. 
estimation  of  duration  of,  173. 
examination,  preliminary,  during,  177. 
exanthemata  during,  435. 
exercise  during,  175. 
extra-peritoneal,  543. 


Pregnancy,    extra-uterine.      (See    Extra-ute- 
rine Pregnancy.) 
floating  kidney  in,  446. 
foetal  heart  in,  158. 

formation  of  lower  uterine  segment,  209. 
funic  souffle  in,  159. 
gingivitis  in,  463. 
glandular  hyperplasia   of  decidua   during, 

480. 
glycosuria  in,  445. 
goitre  in,   464. 
gonorrhoea  in,  438. 

hsematoma  of  abdominal  walls  in,  465. 
hsematuria  in,  445. 
haemoglobin  during,  153. 
haemophilia  in,  449. 
heart,  hypertrophy  of,  in,  153. 
Hegar's  sign  of,  163. 
hepato-toxsemia  in,  456. 
herpes  gestationis  in,  449. 
hydatidiform  mole  in,  485. 
hydraemia  in,  153. 
hydramnios  in,  493. 
hydrorrhoea  gravidarum  during,  480. 
hymen  in,  30,  169. 
hyperemesis   in,   460. 
hypertrophic  elongation  of  cervix  during, 

477. 
hypertrophy  of  cervix  in,  168. 
hysteria  in,  448. 
icterus  in,  444. 
imaginary,  168. 

impetigo  herpetiformis  in,  449. 
incarceration  of  uterus  during,  474. 
incontinence  of  urine  in,  166,  474. 
indigestion  in,  444. 

infection  of  uterine  contents  during,  339. 
inflammation  of  Bartholin's  glands  during, 

467. 
influenza  in,  437. 
inguinal  hernia  during,  477. 
in  rudimentary  horn  of  double  uterus,  469. 
insanity  during,  465,   812. 
intermittent  contractions  of  uterus  during, 

164. 
interstitial,  539. 
in  uterus  bicornis,  471. 
in  uterus  unicornis,  471. 
isthmic,  539. 
kidney  of,  154,  456. 
lactosuria  in,  445. 
laparotomy  during,  475. 
lead  poisoning  in,  449. 
leukaemia  in,  140,  344,  449. 
localized  thickening  of  decidua  during,  4S0. 
malaria  in,  140,  439. 
mammae  in,  152,  165,  318. 
management  of,  175. 
mapping  out  foetus  in,  160. 
marital  relations  in,  176. 
measles  in,  436. 
menses,  cessation  of,  during,  164. 

persistence  of,  during,  165. 
mental  and  emotional  changes  in,  166. 
mental  derangements  in,  465. 
metritis  during,  482. 


INDEX 


839 


Pregnancy,  milk  in.  165,  318. 
missed  abortion  in.  530. 

morning  sickness  in,  460. 

movements  of  foetus  during,  160. 

multiple.    (Sec  Multiple  Pregnancy.) 

myocarditis  in.  443. 

nausea  and  vomiting  during,   L65. 

nephritis  in.   I 15",   156. 

nervous  irritability  in.   154,  156,  465. 

neuralgia  in.  447. 

neuritis  in,  447. 

oedema  in.  152,  463. 

ovarian,  536. 

cyst  complicating,  168,  340. 
ovulation  during,  150. 
palpation  during,  178,  186. 

of  foetal  heart  in..  159. 
paradoxical  incontinence  of   urine   during, 

474. 
paralysis  in.  447. 
paraplegia  in.  447. 
pathology  of,  435. 
pelvimetry  during.  178. 
pendulous  abdomen  in,  162. 
periuterine  inflammation  during,  482. 
pernicious  anaemia  in,  44S. 

vomiting  of,  4G0. 
pessary  in.  473. 
phlegmasia  in,  44.'!. 
physiology  of.  145. 
phthisis  in,  438. 
pigmentation  in,  166. 
placental  souffle  in,  159. 
placentitis  in,  507. 
pneumonia  in,  437. 
positive  signs  of.  158. 
presumptive  signs  of.  164. 
probable  signs  of,  161. 
prolapse  of  uterus  during,  476,  573. 
prolonged,  171,  343. 
pruritus  in,  450. 
psychoses  during,   155. 
pulmonary  embolism  in,  443. 
pulse  in,  305. 

pyelonephritis  in,  344,  446. 
quickening  in,  166. 
relaxation  of  pelvic  joints  during,  465. 

of  vaginal  outlet  during,  467. 
renal  insufficiency  during,  339. 
respiration  in,  154. 

retroflexion  of  uterus  during,  339,  472. 
retroversion  of  uterus  during,  472. 
rupture  of  uterus  during,  738. 
sacculation  of  uterus  in,  168,  473. 
salivation  in,  154,  463. 
scarlet  fever  in,  436. 
sepsis  in,  437. 

sexual  intercourse  during,  176. 
signs  of,  157. 
signs  of  previous,  169. 
size  of  uterus  in.  145,  161. 
small-pox  in.  435. 
souffle,  funic,  in,  159. 
spurious.  168. 
stripe  of,  151. 
suppression  of  menses  in,  164. 


Pregnancy,  surgical  operations  during,    150. 
symptoms  of.  157. 

syphilis   in,     I  In. 

tasie,  perversions  of,  in,  166. 

terminal  ion  of,  171. 

tetanus  in,  438. 

tetany  in.  4  18. 

thyroid    in,   151,   464. 

toothache   in,   463. 

torsion  of  cord  in,  510. 

toxaemia  of,  343,  455. 

transmission   of    bacteria    from    mother   to 

fan  us,   140. 
tubal,  539. 

tuberculosis  in,  140,  .",44,  438. 
tubo-abdomlnal,  539. 
tubo-ovarian,  539,  544. 
tubo-uterine,  544. 
tumours  complicating,  4*3. 
typhoid  fever  in,  140,  437. 
umbilical  hernia  during,  478. 
umbilicus  in,  161,  478. 
urea,  amount  of,  during,  153. 
urinary  disturbances  during,  166. 
urination  during,  154. 
urine,  examination  of,  during,  177. 
urine  in,  153. 
uterine  displacements  in,  472. 

haemorrhage  during,  339. 

myomata  during,  340. 

souffle  in,   159. 
utero-abdominal,  739. 
uterus  in,  105,   145,  162,  213. 
vagina  in,  150,  222,  467. 
vaginal  enterocele  during,  477. 

examination  during,  179,  188. 
vaginitis  during,  467. 
valvular  lesions  of  heart  in,  441. 
varices  in,  443,  467. 
varicose  veins  in,  152,  176. 
variola  in,  435. 
vomiting  of,  339. 
weight  in,  154. 
Preliminary  examination  during  pregnancy, 

177. 
Premature  labour  in  chronic  nephritis,  445. 
in  heart  disease,  442. 
in  lead  poisoning,  449. 
in  leukaemia,  449. 
in  malaria,  440. 
in  ovarian  tumours,  576. 
in  pneumonia,  437. 
in  syphilis,  441. 
treatment  of,  530. 
Premature  labour,  induction  of,  341. 
for  acute  nephritis,  343. 
for  cardiac  lesions,  343. 
for  chorea,  344,  447. 
for  contracted  pelves,  341,  634. 
for  diabetes,  344. 
for  excessive  size  of  child,  343. 
for  habitual  death  of  foetus.  345. 
for  heart  disease,  442. 
for  hydatidiform  mole,  344. 
for  hydra mnios,  344. 
for  neuritis,  344. 


840 


OBSTETRICS 


Premature  labour,  induction  of,  for  old  ex- 
tra-uterine pregnancy,    552. 

for  ovarian  tumours,  344. 

for  pernicious  anaemia,  344. 

for  placenta  praevia,  345. 

for  pyelo-nephritis,  344. 

for  toxaemia  of  pregnancy,  343,  460. 

for  tuberculosis,  344,  439. 

for  uterine  myomata,  344. 

methods  of,  345. 
Premature  separation  of  normally  implanted 

placenta,  713. 
Preparations  for  labour,  275. 
Prepuce  of  clitoris,  26. 
Presentation,  180. 

acromio-iliac.      (See   Transverse   Presenta- 
tion.) 

anterior  parietal,  618. 

breech,  182,  256. 

brow,  181,  253. 

causation  of,  185. 

cephalic,  181. 

compound,  691. 

diagnosis  of,  186. 

ear,  619. 

face,   181,  246. 

foot,  182. 

frank  breech,  1S2. 

frequency    of    the    several    varieties    of, 
184. 

funic,  747. 

head,  181. 

knee,  182. 

lateral  plane,  686. 

mento-iliac.     (See  Face  Presentation.) 

nomenclature  of,  182. 

nuchal,  692. 

occipito-iliac.     (See  Vertex  Presentation.) 

pelvic,  181,  256. 

posterior  parietal,  619. 

reasons  for  predominance  of  head,  185. 

sacro-iliac.    (See   Breech  Presentations.) 

shoulder,  180,  686. 

sincipital,  181. 

transverse,  180,  686. 

vertex,  181,  226. 
Presentation  and  position,  180. 

diagnosis  of,  186. 

frequency  of,  184. 

in  contracted  pelves,  617. 

nomenclature  of,  182. 
Presenting  part,  180. 
Presumptive  signs  of  pregnancy,  164. 
Primary  segments,  90. 
Primitive  folds,  89. 

groove,  89. 

streak,  89. 
Primordial  follicle,  59,  62. 

ova,  59. 
Probable  signs  of  pregnancy,  161. 
Prolapse  of  placenta.  715. 

of  pregnant  uterus,  573. 

of  puerperal  uterus,  805. 

of  umbilical  cord,  624,  747. 
Prolonged  labour,  562. 
pregnancy,  171. 


Pronucleus,  female,  85. 

male,  87. 
Prophylactic  douche,  427,  776. 

version,  634. 
Protovertebrae,  90. 
Pruritus  during  pregnancy,  450. 

vulvae,  450. 
Pseudocyesis,  168. 

Pseudo-osteomalacic  rhachitic  pelvis,  607. 
Psychoses  during  pregnancy,  155. 

puerperal,  812. 
Pubis,  4. 

arch  of,  4. 
Pudendum,  23. 
Puerperal  infection,  757. 

aetiology  of,  769. 

antistreptococcic  serum  in,  790. 

auto-infection,  cause  of,  772. 

bacteriological    examination   of    lochia    in, 
783. 

bacteriology  of,  757. 

curettage  in,  430,  786. 

diagnosis  of,  781. 

frequency  of.  776. 

hysterectomy  for,  790. 

intra-uterine  douche  in,  428.  787. 

operative  treatment  of,  789. 

pathological  anatomy  of,  762. 

pyaemia  in,  768,  779. 

sapraemia  in,  761. 

septicaemia  in,  757,  780. 

sewer  gas  in,  771. 

symptoms  of,  777. 

treatment  of,  785. 
Puerperium,  301. 

acetonuria  during.  308. 

after-pains  in,  306,  310. 

albuminuria  during,  307. 

anatomical  changes  in,  301. 

anteflexion  of  uterus  during,  804. 

atrophy  of  uterus  during,  803. 

binder  in,  309. 

breasts,  diseases  of,  during,  807. 

care  of  patient  during,   308. 

catheterization  during,  311. 

changes  in  blood  during,  306. 
in  lower  uterine  segment  during,  303. 
in  uterine  vessels  during,  302. 

clinical  aspects  of,  304. 

constipation  during,   311. 

cystitis  during,  799. 

death  during,  753. 

diabetes  during,  308. 

diet  during,  310. 

diphtheria  during,   815. 

embolism  in,  755. 

ergot  in,  294,  568,  788. 

gangrene  of  lower  extremities  during,  799. 

general  functions  during,  307. 

glycosuria  during,  308. 

heematoma  during,  801. 

haemorrhage  during,  800. 

incontinence  of  urine  during,  800. 
infection  during,  757. 

insanity  during,  813. 

lactosuria  during,  308. 


INDEX 


841 


Puerperium,  laxatives  In,  311. 

leucocytosls  during,  306. 

lochia  during,  306. 

lochlometra  during,  804. 

loss  of  weigh!  during,  .'ins. 

malarial  fever  during,  814. 

managemenl  of,  308. 

mastitis  during,  sit). 

measles  during,  815. 

milk  iVvit  in.  ::ic.  7M. 

neurit  is  during,  si  it;. 

nursing  in,  321. 

ovarian  tumours  in,  578. 

paralysis  during,  805. 

pessary  during,  804. 

phlegmasia  alba  dolens  during,  798. 

pneumonia  during,  814. 

pndapse  of  uterus  during,  805. 

psychoses  during,   812. 

pulse  during,  305. 

pyelo-nephrosis  during.  799. 

retention  of  urine  during,  308,  800. 

retroflexion  of  uterus  during,  804. 

scarlet  fever  during,  814. 

small-pox  during.  815. 

subinvolution  of  uterus  during,  802. 

syncope  in.  754. 

temperature  during.   304,   310. 

tetanus  during.  797. 

thrombosis  during.  798. 

typhoid  fever  during.  814. 

urination  during.  311. 

urine  in,   307. 

uterine  myomata  in.  575. 

vulval  toilet  during.  309. 

weight,  loss  of,  during.  308. 
Pulmonary  embolism.     (See  Embolism,   Pul- 
monary.) 
Pulse  during  puerperium,  305. 
Pyaemia,  768.  779. 
Pyelo-nephritis,  344. 

during  pregnancy,  446. 
puerperium.  799. 
Pygopagus,  680. 

Quadruplet  pregnancy.  (See  Multiple  Preg- 
nancy, i 

Quickening.  166. 

Quinine  as  an  oxytocic,  565. 

Quintuplet  pregnancy.  (See  Multiple  Preg- 
nancy, i 

"  Rapport  azoturique."  705. 

Rectocele  complicating  labour,  578. 

Recto-vaginal  fistula,  623. 
septum.  32. 

Rectum,    carcinoma    of,    complicating   preg- 
nancy. 579. 
in  labour.  225. 

Red  infarcts  of  placenta.  505. 

Reduction  of  retroflexed  pregnant  uterus, 
475. 

Reichert's  ovum.  88. 

Relapsing  fever  in  pregnancy,  140. 

Relative  indications  for  Caesarean  section, 
402. 


Relaxation  of  pelvicjoints  In  pregnancy, 465. 
of  vaginal  out  In  after  labour,  734. 
of  vaginal  outlet  during  pregnancy,  467. 
Renal  Insufficiency,  339. 
Repeated  Caesarean  section,   to'.'. 

tubal  pregnancy,  551. 
Repositor  for  prolapsed  umbilical  cord,  748. 
Respiration,  artificial,  751. 
in  pregnancy,  154. 
lntra-uterine,   749. 
Restitution.    (See  External  Rotation.) 
Retained  placenta.  27:;.  4.;2.  72.",. 
Retention  of  urine,  311. 
Reticulum  of  endometrium, '43. 
Retinitis,  albuminuric,  696. 
Retraction  ring.    (See  Contraction  Ring.) 
Retractores  uteri,  45. 
Retroflexion,  cause  of  abortion.  523. 
due  to  contracted  pelvis,  616. 
of  bicornuate  uterus.  472. 
of  pregnant  uterus,   339.  472. 
of  puerperal  uterus,  804. 
Retro-mammary  abscess,  811. 
Retro-peritoneal  phlegmon.   768. 
Reynolds's  cervical  dilator.  349. 
Rhachitic  dwarf  pelvis.  042. 
Rhachitis,   diagnosis  of,   610. 
foetal,  609. 
mode  of  production  of  pel^Kc  deformity  in, 

608. 
pathology  of.  601. 
pelvis  in,  603. 
Rhomboid  of  Michealis,  587. 
Rima  pudendi.  23. 
Ring  of  Bandl.    (See  Contraction  Ring.) 

of  Muller,  208. 
Ritgen's  method  of  expression,  2SS. 
Robert  pelvis,  648. 
Roentgen  ray  in  determining  size  of  pelvis, 

594. 
Rosenmiiller.  organ  of.  44. 
Rotation  with  forceps,  368. 
Round  ligaments.   44. 
function  of,  during  labour,  199. 
palpation  of,  188. 
Rubber  gloves,  use  of,  189. 
Rupture  of  Graafian  follicle,  66. 
of  pelvic  joints,  623. 
of  umbilical  cord,  510. 
of  uterus,  738. 
aetiology  of.  739. 
at  time  of  labour,  739. 
during  pregnancy.  738. 
in  contracted  pelves.  622. 
in    neglected    transverse    presentations, 

687,  740. 
in  pregnancy  in  bicornuate  uterus.  471. 
in  scar  following  Caesarean  section.  409. 
repeated.   740. 
symptoms  of.  742. 
treatment  of.  743. 

Sacculation  of  uterus,  168. 
Sacro-iliac  synchondrosis.  10. 

rupture  of,  in  labour,  623,  806. 

synostosis  of,  644. 


842 


OBSTETRICS 


Sacro-sciatic  notch,  3. 
Sacrum.  3. 

assimilation     of,      to     vertebral     column, 
651. 

imperfect  development  of,  651. 

not  a  keystone,  4. 

promontory  of,  3. 
Sagittal  fontanelle,  135. 

suture,  135. 
Salivation  in  pregnancy,  154,  463. 
Salpingitis,   puerperal,   768. 
Salt  solution  in  eclampsia,  709. 

in  haemorrhage,  730. 
Saprsemia.  761. 

Sarcoma  uteri  deciduo-cellulare,  490. 
Saxtorph's  manoeuvre.  375. 
Scanzoni's  manoeuvre,  371. 
Scarlet  fever  in  pregnancy,  436. 

in  puerperium,   436,   814. 

intra-uterine,  436. 

relation  of,  to  puerperal  infection,  771. 
Scheele's  method  of  inducing  labour,  345. 
Schirrus  of  placenta,  503. 
Schultze's   mechanism   of   extrusion   of   pla- 
centa, 266. 

method  of  resuscitation,  752. 
Scolio-rhachitic  pelvis,  661. 
Scoliosis,  661. 
Scoliotic  pelvis,  661. 
Seat-worms,  450. 
Segmental  layer,  90. 
Segmentation  nucleus,   S7. 
Semen,  86. 
Sepsis  foudroyante,  762. 

in  pregnancy,  437. 
Septicaemia,  puerperal,  780. 
Sewer  gas  in  puerperal  infection,  771. 
Sex,  determination  of,  143,  159. 

diagnosis  by  heart-beat,  159. 
Sexual  intercourse  in  pregnancy,  176. 

organs,  abnormalities  of,  467,  569. 
Shock  during  labour,   753. 
Shortening    of    cervix,    apparent,    in    preg- 
nancy, 208. 
Shoulder     presentation.       (See     Transverse 
Presentation.) 

delivery  of,  289. 
Show,  200. 

Signs  of  pregnancy,  157. 
Simple  flat  pelvis,  599. 
Simpson's    basilyst,   422. 

cranioclast,   421. 

forceps,  351,  356. 
Skull,  configuration  of,  624. 

depression  of,  625. 

fracture  of,  388,  625. 

pressure  marks  on,  625. 
Skutsch's  pelvimeter,  592. 
Slow  pulse  during  puerperium.  305. 
Small-pox  during  pregnancy,  435. 

during  puerperium,  815. 

intra-uterine,  140,  435. 
Smellie's  forceps,  355. 

scissors,  419. 
Somatopleure,  91,  94. 
Souffle,  funic,  159. 


Souffle,    placental,   159. 

uterine,  159. 
Spee's  ovum,  90. 
Spermatozoa,  SO,  86. 

entrance  into  ovum,  86. 

mode  of  entry  into  uterus,  80. 

number  of,  80. 
Sphincter  vaginae.  33. 
Splanchnopleure.  91.  94. 

Spleen,    enlarged,   complicating  labour,   578. 
Split  pelvis,  649. 
Spondylizeme,  658. 
Spondylolisthesis,  664. 
Spondylolysis,  666. 

Spontaneous  amputation  by  amniotic  adhe- 
sions, 499. 

evolution,  688.  ,- 

version,  688. 
Spurious  pregnancy,  168. 
Stages  of  labour,  199. 

Staphylococcus  in  puerperal  infection,  758. 
Stein's  pelvimeter,  592. 
Stenosis  of  umbilical  vessels.  495. 
Sterilization  of  patient  after  Caesarean  sec- 
tion, 407. 
Stigma  folliculi.  64. 
Straits  of  pelvis.  4. 
Streptococcus  in  mammary  abscess,  811. 

in  puerperal  infection,  758. 

in  puerperal  insanity,  813. 
Striae  of  pregnancy.  151. 
Subareolar  mastitis,  811. 
Subinvolution  of  uterus,  802. 

curettage  in,  430. 
Succenturiate  placenta,  502. 
Sudden  death  during  labour,  753. 
Sugar  in  urine,  307,  445. 
Superfecundation,  330. 
Superfoetation,  330. 
Superior  strait,  4. 
Surgical      operations      during      pregnancy, 

450. 
Sutures  of  head,   135. 

for  perineal  repair,  298. 
Symphyseotomy,  history  of.  410. 

in  brow  presentations.  256. 

in  contracted  pelves,  629. 

in  face  presentations,  253. 

in  Naegele  pelvis,  647. 

in  spondylolisthetic  pelvis,  669. 

indications  for,  412. 

prognosis  of,  413. 

technique  of.  412. 
Symphysis  pubis,  2,  10. 

absence  of,  649. 

rupture  of,  in  labour,  623,  806. 

separation  of,  during  labour,  1. 
Synchondrosis,  sacro-iliac,  10. 
Synclytism,   232. 
Syncope  during  labour,  754. 
Syncytioma  malignum,  490. 
Syncytium,  102,  491. 

in  eclampsia,  704. 

in  lungs,  in  eclampsia,  702. 
Syphilis,  bone  lesions  in,  513. 

during  pregnancy,  440. 


INDEX 


843 


Syphilis,   foetal,  51L, 
pathology  of,  512. 

placenta]  lesions  In,  515. 

posl  -conceptlonal,  441. 

transmission  of,  to  foetus,  441. 
Syphilitic  osteo-chondrltls,  514. 

Tampon,   £31. 

in  abort  Ion,  529. 

in  placenta  praevia,  723. 

in  post-partum  haemorrhage,  729. 

in  rupture  of  uterus,  744. 
Tardy  labour,  562. 
Tarnier's  basiol  ribe,  421. 

cephalotribe,  421. 

excitateur  uterin,  340. 

forceps,  370. 
Temperature  during  labour,  305,  506,  780. 

during  puerperium,  305. 
Temporal  fontanelle,   135. 
Tetanic  contraction  of  uterus,  567,  622. 
Tetanus  during  pregnane}',  438. 

in   puerperium,   797. 

uteri.   567. 
Tetany  in  pregnancy,  448. 
Theca  folliculi,  64. 
Third   stage  of   labour.    (See  Placental  Pe- 

riod.  I 
Thoracopagus.    681 '. 
Threatened  abortion,  -"27. 
Thrill    in   uterine  artery   during  pregnancy, 

159. 
Thrombosis  of  uterine  vessels,  302. 

of  vessels  of  lower  extremities,   79S. 
Thyroid,  cause  of  dystocia.  685. 

cause  of  face  presentations.   247. 

changes  in,  during  pregnancy.  154. 
Toothache  in  pregnancy,  463. 
Torsion  of  cord,   510. 

of  uterus..  149. 
Touch,  vaginal,  during  labour.  278,  281. 

in  pregnancy,  162,  188. 
Toxaemia  of  pregnancy,  343,  455. 

lesions  of,  456. 

relation  of,  to  eclampsia,  694,  698. 

treatment  of,  456. 

urine  in.  456. 
Trachelo-rhekter,  425. 

Transfusion  of   salt   solution   in   eclampsia, 
709. 

in  extra-uterine  pregnancy,  555. 

in  post-partum  haemorrhage.  730. 
Transplantation  of  ovaries,  58. 
Transportation  of  chorionic  villi,  489,   702. 
Transverse  presentations,  180,  686. 

cephalic  version  in.  392.  690. 

course  of  labour  in.  t;s7. 

decapitation  in.  424,  691. 

diagnosis  of,  687. 

podalic  version  in,  394.  396.  690. 
Transversely  contracted  pelvis.  648. 
Transversns  perinei.  222.  296. 
Trepanation  for  asphyxia  neonatorum.   753. 
Triplet     pregnancy.       (See     Multiple     Preg- 
nancy, i 
Trophoblast,  95,  113,  116. 


True  dwarf  pe\\  is.  642. 
Tubal  abort  Ion,  540. 

pregnancy.   7>::i. 
Tuberculosis  during  pregnancy,  438. 

of  placenta,   139,  507. 

transmission  of,  to  foetus,  439. 
Tuberous  subchorial  hematoma  of  decidua, 

526. 
Tnlies,  Fallopian.     (See  Fallopian  Tubes.) 
Tumours,   abdominal,    diagnosis  of,   in   preg- 
nancy. 167,  574. 

complicating  pregnancy,  483. 

fibroid,  of  uterus.  571. 

of  foetus,  683. 

of  pelvis,  676. 

of  placenta.  506. 

osseous,  deforming  pelvis,  676. 

ovarian,   168,  576. 

phantom,  differentiation  of,  from  pregnan- 
cy, 169. 

scalp,  243,  251,  255,  624. 

vaginal,  570. 
Tunica  externa  of  Graafian  follicle,  64. 

interna,  64. 
Turning.    (See  Version.) 

Twin  pregnancy.    (See  Multiple  Pregnancy.) 
Twins,  collision  of,  334. 

locked,  334. 
Tympania  uteri,  759. 
Tympanites  uteri,  623. 
Typhoid     bacilli,     transmission     to     foetus, 

140. 
Typhoid  fever  during  pregnancy,  437. 

in  puerperium,  782,  814. 

Ulcer,  puerperal,  762. 
Umbilical  arteries,  138. 

infection,  315. 

vesicle,  124. 
relation  to  velamentous  insertion  of  cord, 
509. 
Umbilical  cord,  121,  122. 

abnormalities  of,  508. 

battledore,  insertion  of,  508. 

care  of,  315. 

coils  of.  about  neck  of  child,  289. 

cysts  of,  511. 

dermoid  of,  511. 

development  of,  123.   . 

formation  of.  123. 

haeniatoma  of,  511. 

hernia  of,  510. 

infection  of.  315. 

inflammation  of,  510. 

knots  of,  510. 

laceration  of,  510,  567. 

ligation  of,  290. 

loops  of,  510. 

marginal  insertion  of.  508. 

myxoma  of,  511. 

oedema  of,  511. 

prolapse  of.  624.  747. 

reposition  of,  748. 

rupture  of,  510. 

sarcoma  of,  511. 

shortening  of,  510. 


844 


OBSTETRICS 


Umbilical  cord,  souffle  in,  159. 
stenosis  of  vessels  of,  495. 
strangulation   of,    by   amniotic   adhesions, 

499. 
torsion  of,  510. 
tumours  of,  511. 
tying  of,  315,  290. 
variations  in  length  of,  509. 

varices  of,  511. 

velamentous  insertion  of,  508. 
Unavoidable  haemorrhage,  715,  718. 
Uraemia  in  eclampsia,  699. 

in  retroflexion  of  pregnant  uterus,  475. 
Urea  in  eclampsia,  698. 

in  pregnancy,  153,  459. 
Ureometer,   Doremus's,  459. 
Ureter,  compression  of,  cause  of  eclampsia, 

699. 
Urethra,  27. 
Urethral  opening.  27. 
Urinary  disturbances  in  pregnancy,  166. 
Urine,    examination    of,    during    pregnancy, 
177. 

incontinence  of,  474,  745,  800. 

in  eclampsia,  697. 

in  pregnancy,  153. 

in  puerperium,  306. 

in  toxaemia  of  pregnancy,  457. 

of  foetus.  105,  141,  494,  498. 

retention  of,  during  puerperium,  308. 
Uterine  atony,  726. 

bruit,  159. 

glands,  41. 

inertia,   563. 

insufficiency,  563. 

milk,  119. 

paralysis,  726. 

souffle,  159. 
Uterus,  non-pregnant,  35-51. 

anatomy  of,  35. 

blood-vessels  of,  45. 

cervix  of,  36. 

development  of,  49. 

ligaments  of,  43. 

lymphatics  of,  48. 

mucosa  of,  39. 

musculature  of,  43. 

nerves  of,  49. 

position  of,  45. 

weight  of,  36,  145. 
Uterus,  parturient,  action  of,  in  labour,  208. 

anteflexion  of,  572. 

faulty  contraction  of,  564. 

hour-glass  contraction  of,  568. 

myoma  of,  574. 

perforation  of,  744. 

retroflexion  of,  572. 

rupture  of,  622,  687,  738. 

sacculation  of,  572. 

tetanus  of,  622. 
Uterus,  pregnant,  abnormalities  of,  468. 

anteflexion  of,  148,  162,  472. 

anteversion  of,  472. 

atrophy  of  decidua  causing  abortion,  481. 

atrophy  of  decidua  causing  placenta  prae- 
via,  720. 


Uterus,  pregnant,  bicornis,  472. 
carcinoma  of,  468. 
changes  in  cervix,  162. 
changes  in,  during  contractions,  198. 
changes  in  size  and  shape  of,  148. 
consistency  of,  162. 
contractions  of,  164,  208. 
developmental  abnormalities  of,  468. 
double,   with  rudimentary  horn,  469. 
duplex,  469. 
hypertrophy  of,  145. 
incarceration  of  retroflexed,  474. 
involution  of,  301. 

laceration  of  cervix  of,  169,  344,  725,  736. 
lateral  displacements  of,  476. 
malformations  of,  468. 
muscle  layers  of,  146. 
myoma  of,  574. 
nerve  supply  of,  195. 
perforation  of,  744. 
prolapse  of,  573,  476. 
pseudo-didelphys.  469. 
retroflexion  of,  472. 
retroversion  of,  472. 
sacculation  of,  168,  472. 
shape  of,  148. 
sinking  of,  173. 
torsion  of,  149. 
tumours  of,   complicating  pregnancy,   468, 

574. 
unicornis,  471. 
weight  of,  145. 
Uterus,  puerperal,  anteflexion  of,  804. 
hour-glass  contraction  of,  568. 
inversion  of.  730. 
involution  of,  301,  802. 
lactation  atrophy  of,  803. 
paralysis  of,  726. 
prolapse   of.   805. 
removal  of,  after  Caesarean  section,  406. 

after  rupture,  744.  ■ 

for  infection,  789. 
retroflexion  of,  804. 
subinvolution  of,  430,  802. 
weight  of,  301. 

Vagina,  31. 
atresia  of,  569. 
changes  of,  in  pregnancy,  150. 

in  puerperium,  303. 
closer  of,  33. 

colour  of,  in  pregnancy,  166. 
development  of,  28. 
diphtheria  of,  763. 
double,   472,    570. 
fornix  of,  32. 
functions  of,  31. 
glands  of,  33. 
haematoma  of,  801. 
injuries  of,  during  labour,  734. 
laceration  of.  during  labour,  734. 
mucosa  of,  33. 
neoplasms  of,  570. 
prolapse  of,  in  pregnancy,  467,  476. 
relations  of,  32. 
rugae  of,  32. 


IXI'K.X 


845 


Vagina,  secretion  of,  34. 

septa  in.  570. 

sphincter  of,  33. 

stenosis  of,  570. 

thrombus  of,  801. 

tumours  of,  570. 

ulcer  <>f.  762. 
Vaginal  Caesarean  section,  409. 

douche,  427,  776, 

enterocele,  477. 

examination  during  pregnancy,  179. 

opening.  28. 

outlet,    relaxation    of,    during    pregnancy, 
467. 

secretion,  150. 
in  pregnancy,  77::. 
in   pucrperiuin.  300. 

touch  during  labour,  27S,  2S1. 
in  pregnancy,  102,  188. 
Vaginismus,  571. 
Vaginitis,  407. 

puerperal.   703. 
Vagino-fixation,  cause  of  dystocia,  573. 
Vagitus  uterinus,  750. 
Varicose  veins  in  pregnancy.  152,  443. 
Variety  of  presentation,  1S2. 
Vasa  praevia,  509. 
Veins.    (See  Blood-vessels.) 
Velamentous  insertion  of  cord,  508. 
Venesection  in  eclampsia,  709. 

in  heart  disease,  442. 
Ventro-fixation,  cause  of  dystocia,  572. 
Veratrum  viride  in  eclampsia,  709. 
Vernix  easeosa,  132. 
Version,  391. 

bipolar.     (See  Bipolar  Version.) 

cephalic.     (See  Cephalic  Version.) 

combined,  393. 

external.     (See  External  Version.) 

in  contracted  pelves,  634. 

in  transverse  presentations.  690. 

podalic.    (See  Podalic  Version.) 

prophylactic,  634. 

spontaneous,  688. 
Vertebrae,  primitive.  90. 
Vertex  presentations,  181,  227. 

causation  of,  185. 

diagnosis  of.  228. 

frequency  of.  226. 

mechanism  of,  229. 
Vesical  calculus  complicating  labour,  578. 
Vesicle,   blastodermic,  S7. 

umbilical,  93,  124. 
Vesico-cervical  fistula,  623. 
Vesico- vaginal  fistula,  623,  745. 

septum,  32. 
Vesicular  mole.  4S5. 


Vestibular  bulbs,  27. 
Vestibule,  27. 

glandulse  restibulares  majores,  27. 
minores,  27. 
Villi,  chorionic,  95,  114,  117. 

hyperplasia  of,  506. 

metastases  from,  489. 

syphilitic  changes  in,  515, 

transportation  of,  489,  702. 
Visceral  arches,  129. 

clefts,   129. 
Vision,    disturbances  of,   during  pregnancy, 
448. 
in  eclampsia.  696. 
Vitelline  membrane,  64,  87. 
Vomiting  of  pregnancy,  339. 
Vulva.  23. 

atresia  of.  569. 

clitoris.   26. 

commissure  of,  24. 

diphtheria  of,  763. 

diphtheritic  ulcer  of,  763. 

fourchette  of,  25. 

frenulum  of.  25. 

hsematoma  of.  28,  569. 

hymen,  28. 

injuries  of,  during  labour,  734. 

labia  majora,  24. 
minora,  25. 

oedema  of,   463. 

pruritus  of.  450. 

urethral  opening.  27. 

vaginal  opening,  28. 

vestibular  bulbs,  27. 

vestibular  glands,  27. 

vestibule,  27. 

Walcher's  posture.  11. 

in  contracted  pelves.  631. 
Wegner's  bone  disease.  514. 
Weight,  changes  in,  during  pregnancy,  154. 

loss  of.  during  the  puerperium.  308. 

of  foetus  at  various  months,  13L 

of  newly  born  child,  132. 
Wharton's  jelly.  123. 
"White  infarcts  of  placenta,  503. 

line,  222. 
Wolffian  body.  59. 

ducts,  27,  49. 

X  ray  in  determining  size  of  pelvis,  594. 

Yolk,  66. 
Yolk-sac,  93,  128. 

Zellschicht  of  chorion,  102. 
Zona  pellucida,  65. 


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